■SSiiSHF 


RG104.B3  1911        Vaginalceliotomy/ 


RECAP 


x'/aL 


liii 


iccc.c 


'':<^^^, 


i<<  - 


i 


'<!<'<^0'.^i<^5'^;;^^ 


(K,(" 


Bliiiiiii; 


•Mm 


m 


O  UBRAWIS  ^ 

HEALTH 
SCIENCES 
LIBRARY 


^5^ 


Digitized  by  the  Internet  Archive 

in  2010  with  funding  from 

Open  Knowledge  Commons 


http://www.archive.org/details/vaginalceliotomyOOband 


BOOKS 

BY 

S.  WYLLIS  BANDLER,  M 

D. 

Vaginal  Celiotomy 

Large   octavo   of   450   pages,   with 

148 

original  illustrations.                 Just  Ready 

Medical  Gynecology 

Octavo  of  702  pages,  150  original 

llus- 

trations.     Cloth,    $5.00   net;    Half 

Mo- 

rocco,  $6.50  net.                  Second  Edition 

VAGINAL  CELIOTOMY 


BY 

S.  WYLLIS  BANDLER,  M.  D. 

FELLOW     OF    THE    AMERICAN    ASSOCIATION    OP     OBSTETRICIANS    AND     GYNECOLOGISTS; 
ADJUNCT   PROFESSOR   OF   DISEASES   OF  WOMEN,   NEW   YORK  POSTGRADUATE 
MEDICAL  SCHOOL  AND  HOSPITAL;  ASSOCIATE  ATTENDING  GYNECOLO- 
GIST   TO    THE    BETH    ISRAEL    HOSPITAL,    NEW    YORK    CITY 


WITH  148  ORIGINAL  ILLUSTRATIONS 


PHILADELPHIA  AND  LONDON 

W.  B.  SAUNDERS  COMPANY 

1911 


T 


Copyright,  191 1,  by  W.  B.  Saunders  Company 


PRINTED      IN     AMERICA 


Dedicated 

to 

Professor  Dr.  Alfred  Duhrssen  (Berlin) 

who,  by  his  original  work  in  vaginal 

surgery,  has  raised    the    specialty  of 

gynecology    and     obstetrics     to     the 

dignity  of  a  science 


PREFACE 

My  interest  in  vaginal  celiotomy  dates  back  to  1895.  In  the 
intervening  years  I  have  given  this  method  the  test  of  time  and 
experience. 

I  have  never  given  it  the  extreme  praise  voiced  by  its  most 
faithful  and  enthusiastic  admirers.  I  have  often  wondered  at  its 
almost  complete  neglect  by  a  very  large  share  of  the  surgical  and 
gynecological  world. 

In  the  thorough  correction  of  cystocele,  descensus  uteri,  prolapse 
of  the  uterus;  for  the  performance  of  simple  hysterectomy,  vaginal 
celiotomy  has  a  value  so  great  that  the  abdominal  route  should 
scarcely  enter  into  consideration. 

I  know  of  no  book  which  treats  in  detail  of  these  and  allied 
topics.  For  this  reason  I  offer  this  work  in  the  hope  that  it  may 
suggest  the  value  of  the  vaginal  path  in  the  correction  of  many 
pelvic  gynecological  diseases. 

The  drawings  by  K.  K.  Bosse  have  been  made  after  repeated 
observation  of  the  various  operative  procedures  on  the  living. 

My  sincere  thanks  are  due  the  firm  of  W.  B.  Saunders  Company, 
for  its  exceUent  work  in  the  production  of  this  book. 

S.  W.  B. 

New  York  City,  January,  1911 


13 


CONTENTS 


PAGE 

Posterior  Vaginal  Celiotomy 17 

Technic 17 

Uses  of  Posterior  Vaginal  Celiotomy 28 

For  Differential  Diagnosis 28 

For  Examination 37 

To  Loosen  Adhesions 37 

For  Replacing  Incarcerated  Uterus 37 

For  Delivering  Adnexa  and  Uterus 38 

For  Removing  Ovarian  Cysts 38 

For  Posterior  Parametritis  and  Retrodisplaceraent 47 

For  Drainage 47 

For  Pelvic  Abscess 47 

A  Step  in  Vaginal  Hysterectomy 54 

Anterior  Vaginal  Celiotomy 58 

Separation  of  Bladder  from  Cervix  Uteri 71 

Separation  of  Bladder  from  Anterior  Fornix  and  Anterior  Vaginal  Wall.  78 

Entering  the  Peritoneum 90 

Delivery  of  the  Uterus  and  Adnexa 103 

Indications  for  Anterior  Colpoceliotomy in 

Conservative  Operatio:is 117 

Retrodeviations ■ 129 

How  to  Pass  Uterine  Suspension  or  Fixation  Sutures 138 

Cystocele  and  Vaginofixation 160 

Two  Points  of  Importance  in  the  Performance  of  Vaginofixation 

for  Descensus  Uteri 178 

Total  Prolapse  of  the  Uterus 205 

Result 282 

Simple  Vaginal  Hysterectomy 283 

Operation 286 

Disease  of  the  Adnexa 346 

Indications  and  Limitations  in  Diseases  of  the  Adnexa 348 

Technic 350 

Ectopic  Gestation 358 

Ovarian  Cysts 359 

15 


1 6  CONTENTS 

PAGE 

Hysterectomy 363 

Myomectomy 392 

Portio  Myomata 394 

Cervical  Interstitial  Myomata 394 

Subserous  Myomata  in  Douglas 397 

Corpus  Pedicled  Myomata 397 

Corpus  Subserous  Myomata 397 

Submucous  and  Deep  Interstitial  Tumors 397 

Intraligamentous  Tumors 397 

Hysteromyomectomy 399 

Vaginal  Cesarean  Section 407 

Technic 409 

Indications 417 

Radical  Vaginal  Cesarean  Section 419 

The  Metreurynter  Incision 422 

Minor  Vaginal  Cesarean  Section 431 

Index 445 


VAGINAL  CELIOTOMY. 


POSTERIOR  VAGINAL  CELIOTOMY. 

Vaginal  celiotomy,  which  includes  the  anterior  and  the  posterior 
method,  has  naturally  been  practised  for  many  years  in  the  performance 
of  vaginal  hysterectomy.  Anterior  vaginal  celiotomy  first  gained 
its  real  dignity  when  Mackenrodt  and  Diihrssen  began  to  perform 
vaginal  suspension  and  vaginal  fixation  for  the  correction  of  retro- 
flexions and  retroversions.  From  that  time  on  this  route  found  an 
increasing  number  of  indications  until  it  was  used,  and  can  be  used 
today,  as  a  path  for  the  performance  of  almost  any  operation  included 
under  the  phrase  "operation  for  pelvic  gynecological  disease." 

Posterior  vaginal  celiotomy  is  an  essential  step  in  hysterectomy, 
but,  in  addition,  it  has  great  value  as  a  celiotomy  done  for  the  purpose 
of  diagnosis  and  for  the  surgical  treatment  of  many  pelvic  diseases. 
The  posterior  method,  because  of  its  simplicity  and  lack  of  danger, 
is  of  the  greatest  value  in  diagnosis  and  differential  diagnosis,  even 
though  it  does  not  permit  of  that  clear  view  of  the  various  organs 
granted  by  the  anterior  route.  It  has  the  disadvantage  that  no  correc- 
tion of  a  retroflexion  or  retroversion  can  be  done  by  this  method. 

TECHNIC. 

The  cul  de  sac  of  Douglas  may  be  entered  by  a  transverse  or 
longitudinal  incision  or  by  a  combination  of  the  two.  The  longitudinal 
incision  is  carried  down  through  the  posterior  covering,  of  the  cervix, 

17 


1 8  VAGINAL   CELIOTOMY 

through  the  mucosa  of  the  posterior  fornix,  passing  thus  into  the 
connective  tissue  lying  under  the  cul  de  sac  of  Douglas  and  then 
penetrating  the  peritoneum.  If  not  made  too  long,  if  the  cervix  is 
pulled  well  down  and  if  the  posterior  fornix  is  put  on  the  stretch  by 
a  long  posterior  speculum,  there  is  very  little  danger  of  injuring  the 
rectum,  provided  the  incision  closely  hugs  the  posterior  wall  of  the 
actual  cervix  tissue.  The  longitudinal  incision  may  be  amplified 
by  incisions  made  transversely  (Fig.  i). 

The  cul  de  sac  of  Douglas  may  be  entered  by  a  transverse  incision. 
The  loose  vaginal  tissue  in  the  posterior  fornix  with  its  transverse 
corrugations  may  be  picked  up  i  1/2  to  2  inches  away  from  the  external 
OS  after  the  cervix  is  drawn  well  up  toward  the  urethra,  and  one  snip 
with  the  scissors  close  to  the  forceps  gives  direct  entrance  into  the 
cul  de  sac  of  Douglas  (Fig.  2).  The  advantages  of  this  method  are: 
the  peritoneum  and  the  vaginal  edge  are  readily  brought  into  contact; 
there  is  remarkably  httle  oozing.  The  risk  in  this  method  is:  the 
possibility  of  cutting  into  the  rectum  or  of  injuring  intestine  if  the  lat- 
ter be  present  in  the  cul  de  sac  of  Douglas.  These  risks,  while  not 
great,  are  nevertheless  worthy  of  consideration.  If  the  scissors  do 
not  enter  the  cul  de  sac,  a  slight  dissection  with  the  gauze-covered  finger 
exposes  the  peritoneal  fold  of  Douglas  which  is  picked  up  with  forceps 
(Fig.  3),  and  cut  to  any  desired  width.  The  peritoneum  is  then 
united  to  the  vaginal  edge  by  forceps  or  by  sutures,  either  of  which 
remain  in  place  until  the  desired  operation  is  completed  (Fig.  4). 

The  safest  method  consists  of  a  transverse  incision  made  nearer 
to  the  external  os,  but  is,  unfortunately,  the  bloodiest,  for  the  loose 
connective  tissue  under  the  cul  de  sac  of  Douglas  and  between  the 
cervix  and  the  rectum  oozes  considerably,  especially  at  the  lateral 
margins  of  the  transverse  incision.  With  the  cervix  pulled  well  up 
toward  the  urethra  a  transverse  incision  is  made  across  the  cervix 
throughout  its  entire  width  and  passing  well  down  to  the  structure 
of  the  cervix.     The  lower  margin  of  the  incision  is  grasped  with 


POSTKRIOR    VAGINAL    CELIOTOMY 


19 


Fig.  I. — Posterior  Vaginal  Celiotomy. 


A  longitudinal  incision  in  the  posterior  fornix  amplified  by  two  transverse  cuts.  The  cervix 
is  pulled  up  toward  theurethra,  the  knife  makes  a  long  longitudinal  incision  beginning  at  the  point 
where  themucosa  begins  to  be  loosely  attached  to  the  posterior  wall  of  the  cervix.  The  point  of 
the  knife  should  stick  closely  to  the  structure  of  the  cervix  itself.  After  the  incision  in  Douglas 
has  been  carried  to  the  desired  length,  two  transverse  cuts  are  made  at  the  lowest  area  of  the 
peritoneal  incision.  If  a  transverse  incision  is  made  first  the  added  longitudinal  cut  may  be 
made  subsequently.  The  peritoneum  may  be  united  to  the  vaginal  mucosa  by  several  interrupted 
sutures  as  shown  above. 


POSTERIOR    VAGINAL    CELIOTOMY 


21 


Fig.  2. — Posterior  Vaginal  Celiotomy. 


If  the  loose  vaginal  mucosa  in  the  posterior  fornix  is  picked  up  firmly  i  1/2  to  2  inches  away 
from  the  external  os  and  if  scissors  be  held  in  a  horizontal  direction,  it  is  generally  possible  to 
incise  the  vaginal  mucosa  and  the  peritoneal  fold  of  Douglas  at  the  same  time.  The  length  of 
this  transverse  incision  may  be  increased  toward  either  side.  There  is  very  little  oozing  and  the 
peritoneum  may  be  united  to  the  vaginal  mucosa  by  forceps  or  sutures. 


POSTERIOR   VAGINAL   CELIOTOMY 


23 


Fig. 


-Posterior  Vaginal  Celiotomy. 


If  the  transverse  cut  with  the  scissors  is  made  a  little  nearer  to  the  external  os  than  in 
Fig.  2  the  peritoneumis  not  incised,  but  is  brought  directly  into  view.  A  httle  dissection  is  made 
with  gauze-covered  index  finger,  and  then  the  peritoneum  is  picked  up  and  incised. 


POSTI'.RIOR    VAGINAL   CELIOTOMY 


25 


Fig.  4. — Posterior  Vaginal  Celiotomy. 


The  lower  edge  of  the  peritoneal  apron  on  the  posterior  wall  of  the  cul  de  sac  of  Douglas  may 
be  picked  up  with  the  forceps  or  hooked  with  the  index  finger  and  brought  into  ready  contact  with 
the  vaginal  edge  and  united  by  sutures  or  by  long  artery  forceps  or  clamps.  This  gives  roomy, 
unhindered  entrance  into  the  peritoneal  cavity  for  any  examination  or  manipulation  and  retains 
the  peritoneum  where  it  may  be  sewed  or  made  use  of  in  any  desired  fashion  subsequenth'. 


POS'll'.RIOR    VAOINAL   CELIOTOMY  27 

one  or  two  forceps  wiiich  Ijrings  the  ccjnncctive  tissue  Ijands  uniting 
it  to  the  posterior  wall  of  the  cervix  into  view.  These  bands  may 
be  cut  through  with  short  sni])s  of  a  blunt-pointed  scissors  (Fig.  5), 
the  tijj  of  the  scissors  being  held  very  close  to  the  structure  of  the 
cervix  itself.  The  index  linger  covered  with  gauze  then  further 
scjKirates  these  bands  and  soon  the  peritoneum  of  the  cul  de  sac  of 
Douglas  is  reached.  This  may  be  grasped  with  forceps  and  cut  wath 
the  scissors;  or  it  may  be  perforated  with  the  finger  or,  by  further 
separation  of  its  connection  to  the  posterior  wall  of  the  cervix,  this 
peritoneal  pouch  may,  with  the  aid  of  the  index  finger  be  peeled  of^ 
from  the  posterior  wall  of  the  cervix  and  uterus  for  a  further  distance 
of  one  or  more  inches.  (This  added  upw^ard  dissection  of  the  peri- 
toneum from  the  posterior  wall  of  the  uterus,  when  extended  laterally 
by  the  introduced  linger,  enables  us  to  reach  and  perforate  pus  sacs  sit- 
uated lateral  to  the  sac  of  Douglas  without  entering  the  free  peritoneal 
cavity  (see  page  154).)  The  peritoneum  may  then  be  grasped  wnth 
the  scissors  and  cut  through,  or  it  may  be  perforated  with  the  index 
finger.  Peritoneum  is  united  to  vaginal  edge  by  forceps  (Fig.  4)  or 
by  sutures  (Fig.  6).  The  longitudinal  incision  mentioned  above 
may  be  amplified  by  a  transverse  one,  giving  in  that  event  a  large 
opening  (Fig.  i). 

The  peritoneum  may  be  entered  by  a  longitudinal  incision  made 
by  the  scissors  in  the  act  of  splitting  up  the  entire  posterior  wall  of 
the  vaginal  portion  of  the  cervix  through  the  cervical  canal  (Fig.  7). 
This  sphtting,  when  continued,  results  in  entrance  into  the  peritoneal 
cavity  (Fig.  8),  after  which  the  uterus  is  grasped  with  volsellum  for- 
ceps and  the  splitting  of  the  posterior  uterine  wall  may  then  be  con- 
tinued as  far  as  desired.  This  method  is  used  in  gaining  access  to 
fibroids  in  the  posterior  w^all  of  the  uterus,  and  above  the  peritoneal 
fold  of  Douglas.  This  procedure  is  also  the  one  follow^ed  in  doing 
vagina]  hysterectomy  through  the  posterior  incision  according  to  the 
method  of  Doderlein. 


28  VAGINAL   CELIOTOMY 

By  whichever  method  the  cul  de  sac  is  entered,  the  width  of  the 
incision  in  the  peritoneum  may  be  increased  by  cutting  with  scissors 
or  by  stretching  the  gap  with  aid  of  two  introduced  index  fingers  ex- 
erting tension  toward  either  side.  It  is  then  always  advisable  to  bring 
the  posterior  apron  of  the  peritoneum  which  is  over  the  rectum  into 
contact  with  the  adjacent  edge  of  the  vaginal  incision.  This  is  done 
by  applying  one  or  more  long  artery  forceps  or  clamps  or  by  uniting 
the  peritoneum  and  vaginal  edge  by  interrupted  single  sutures  or  by 
several  mattress  sutures.  The  long  ends  of  these  sutures,  when  pulled 
on,  serve  to  bring  this  incision  into  the  cul  de  sac  into  relief  and  to 
markedly  check  the  oozing  from  the  connective  tissue  posterior  to 
the  peritoneum  and  anterior  to  the  rectum ;  in  other  words,  the  posterior 
parametrium.  When  clamps  are  used  instead  of  sutures  they  are 
in  the  way  and  interfere  with  ready  entrance  into  the  peritoneal  cavity. 

USES  OF  POSTERIOR  VAGINAL   CELIOTOMY. 

For  diflferential  diagnosis. — A  high  place  must  be  accorded  to 
posterior  celiotomy  as  a  diagnostic  aid,  more  especially  appreciated  in 
differentiating  intra  uterine  from  extra  uterine  gestation.  The  opera- 
tion is  extremely  simple,  taking  only  one  minute  to  enter  the  peritoneal 
cavity  by  a  longitudinal  or,  preferably,  transverse  incision.  Small 
spurting  vessels  should  be  controlled  by  forceps  or  sutures,  otherwise 
oozing  continues  during  the  entire  examination.  It  is  advisable  in 
the  course  of  the  examination  to  introduce  a  speculum  into  the  perit- 
oneum. If  no  free  blood  or  clots  are  found  in  the  cul  de  sac  of  Doug- 
las, and  if  the  tubes  are  normal,  the  exclusion  of  ectopic  gestation  is 
absolutely  certain.  If  ectopic  gestation  is  disclosed,  the  choice  of 
continuing  the  operation  per  vaginam  by  the  posterior  or  anterior 
route  or  per  abdominem  rests  with  the  surgeon. 

I  have  used  the  posterior  incision  in  very  many  cases  for  verifying 
or  excluding  the  existence  of  an  early  ectopic  gestation  in  cases  where 
the  differential  diagnosis  between  this  condition  and  early  abortion 


POSTERIOR   VAGINAL   CELIOTOMY 


29 


Fig.  5. — Posterior  Waginal  Celiotomy. 

If  a  transverse  incision  is  made  in  the  posterior  wall  of  the  cervix  nearer  to  the  external  os 
than  in  figures  in  2  and  3,  it  is  necessary  to  loosen  the  connective  tissue  bands  connected  with  the 
posterior  wall  of  the  cervix  by  snips  of  scissors  followed  by  rubbings  with  the  gauze-covered  index 
finger.  The  peritoneum  when  reached  may  be  pushed  up  or  dissected  up  from  its  connections 
by  the  index  finger.     The  peritoneum  is  then  perforated  by  the  finger  or  by  forceps  and  scissors. 


POSTERIOR    VA(;ii\AL   VlAAO'lOWX 


31 


Fig.  6. — Posterior  Vaginal  Celiotomy. 


The  peritoneum  is  not  so  easily  grasped  by  forceps  with  the  incision  made  in  figure  5  as  with 
the  incision  in  figures  2  and  3.  It  is  easy,  however,  to  perforate  it  with  the  index  finger,  to  catch 
the  posterior  apron  of  the  peritoneum  with  the  finger,  to  bring  it  down  into  contact  with  the 
vaginal  edge,  and  then  unite  the  two  by  interrupted  sutures.  The  sutures  pass  through  the 
vaginal  mucosa  and  the  peritoneum.  In  the  above  drawing  they  are  attached  more  particu- 
larly to  the  peritoneum  to  show  how  readily  it  can  be  drawn  down. 


V. 


POSTERIOR    YAOIXAL   CKLIOTOMY 


33 


Fig. 


-Posterior  Vaginal  CELiOTOirc. 


The  posterior  wall  of  the  cervix  may  be  split  from  the  external  os  upwards  as  begun  above. 
This  splitting,  if  continued,  cuts  through  the  posterior  fornix  and  the  subperitoneal  connective 
tissue  and  exposes  the  cul  de  sac  of  Douglas.  The  next  stroke  with  the  scissors  enters  the  perit- 
oneal ca%'ity.  If  it  is  desired  to  split  the  cervix  as  far  as  possible  without  entering  the  cul  de  sac 
of  Douglas,  the  index  finger  enters  the  subperitoneal  space  so  soon  as  it  is  invaded  and  dissects 
the  peritoneum  upward. 


POSTI'.RIOR    VAGINAL   CELIOTOMY 


35 


Fig.  8. — Posterior  Vaginal  Celiotomy. 


The  incision  begun  in  figure  7  has  been  continued  through  the  cervix  and  into  the  cul  de  sac 
of  Douglas  and  the  posterior  apron  of  peritoneum  has  been  united  to  the  vaginal  edge.  This 
method  allows  of  approach  to  the  subperitoneal,  interstitial  and  submucous  fibroids  of  the  pos- 
terior uterine  wall  situated  above  the  cul  de  sac  of  Douglas,  and  constitutes  the  first  stage  of 
Doderlein's  method  of  hysterectomy. 


POSTERIOR   VAGINAL    CELIOTOMY  37 

was  in  question.  The  procedure  itself  is  so  simple  that  its  use  need 
not  be  considered  a  performance  of  any  great  moment. 

For  Examination. — -A  thorough  examination  of  the  adnexa  may 
be  carried  out  through  the  posterior  vaginal  incision.  The  external 
hand  is  applied  over  the  abdomen,  two  fingers  of  the  other  hand  pass 
through  the  incision  into  the  peritoneal  cavity  and  in  this  manner, 
bimanual  examination  is  thoroughly  carried  out.  There  are  many 
cases  where  sterility  is  due  to  some  involvement  of  the  tubes  which 
escapes  diagnosis  on  ordinary  bimanual  examination.  The  outer  end 
of  the  tube  may  be  closed  by  adhesions  or  may  be  surrounded  by 
cobweb  adhesions ;  there  may  be  a  small,  soft  hydrosalpinx,  etc.  ^Nlany 
such  cases  are  curetted  for  sterility.  In  many  such  cases  the  Alexander- 
Adams  operation  is  done  for  the  cure  of  sterility.  These  procedures 
could  be  avoided  if  the  diagnosis  of  adhesions  were  made  with  certaintv. 

To  Loosen  Adhesions. — In  cases  of  adherent  retrofiexed  uterus 
or  adherent  prolapsed  adnexa,  whether  operation  be  attempted  entirely 
through  the  posterior  route  or  whether  the  posterior  incision  is  used 
as  an  aid  to  the  anterior,  the  internal  fingers  may  loosen  adhesions 
and  separate  adherent  tubes  and  ovaries.  The  internal  fingers  may 
grasp  the  tube  and  ovary  and  draw  them  into  the  vagina.  \\Tien 
adhesions  to  intestine  are  extremely  dense,  the  greatest  care  of  course 
is  required  in  manipulating  the  internal  fingers  to  avoid  injury  to 
the  intestine. 

For  Replacing  Incarcerated  Uterus. — ^\^ery  few  cases  of  retro- 
flexion cause  trouble  when  pregnancy  takes  place.  In  the  vast  majority 
of  cases  the  uterus  rises  up  out  of  the  pelvis  into  the  abdominal  cavity. 
In  a  few  instances,  where  the  condition  has  not  been  diagnosed  or 
where  a  pessary  has  not  been  used  or  where  the  patient  has  not  been 
kept  under  observation,  incarceration  of  the  pregnant  uterus  is 
threatened  or  actually  occurs.  In  the  early  stages  reposition  of  the 
uterus  by  bimanual  manipulation  or  in  the  knee-chest  position  may 
just  fail  to  lift  the  uterus  past  the  promontory  of  the  sacrum.     In 


38  VAGINAL   CELIOTOMY 

such  cases  posterior  vaginal  incision,  by  permitting  of  the  deep  intro- 
duction of  the  internal  fingers,  may  be  of  service  in  replacing  the 
uterus,  thus  avoiding  abdominal  operation  or  the  occurrence  of  an 
abortion  or  injury  to  the  bladder  through  pressure. 

For  Delivering  Adnexa  and  Uterus. — ^For  the  purposes  of 
examination  and  operation  the  posterior  vaginal  incision  is  indicated, 
when  ovaries  or  ovarian  tumors  lie  deep  or  can  be  pushed  down  and 
can  be  reached  with  the  internal  fingers,  or  if  they  lie  directly  on  or 
close  to  the  posterior  fornix.  The  more  loose  the  various  ligaments  of 
the  uterus,  the  looser,  especially,  the  round  and  broad  ligaments,  the 
more  movable  and  retroflexed  the  uterus,  the  more  expeditiously 
can  the  adnexa  be  delivered  through  the  posterior  vaginal  incision, 
and  this  is  more  true  of  the  uterus.  It  is  hard  to  deliver  the  uterus 
unless  it  is  freely  movable  and  unless  the  ligaments  are  loose  (Fig.  9). 
This  is  particularly  so  in  the  case  of  nuUiparas,  in  many  of  whom  the 
anterior  route  is  to  be  preferred.  Those  cases  in  which  delivery 
of  the  uterus  by  the  posterior  route  is  easy  are  the  very  ones  in  whom 
retroflexion  or  retroversion  is  present  and  in  whom  the  anterior  method 
should  be  chosen,  because  it  permits,  in  addition  to  the  other  proced- 
ures, the  correction  of  the  abnormal  position  by  vagino-suspension 
or  fixation  or  by  shortening  of  the  round  ligaments. 

For  Removing  Ovarian  Cysts. — The  posterior  path  has  for 
years  been  used  to  great  advantage  for  the  removal  of  small  movable 
ovarian  tumors  which  are  prolapsed  into  the  cul  de  sac  of  Douglas. 
In  fact,  it  was  for  the  removal  of  ovarian  cysts  that  this  route  was 
first  used,  and  in  America,  too.  Atlee,  in  1857,  was  the  first  to  do  a 
posterior  vaginal  celiotomy,  though  to  Gaillard  Thomas,  1870,  belongs 
the  credit  of  the  first  deliberate  use  of  this  route.  Diihrssen,  however, 
uses  the  posterior  route  for  the  opening  and  extraction  of  cystic  tumors 
of  the  ovary,  if  they  can  be  reached  by  this  path,  only  in  the  case  of 
pregnancy,  a  condition  which  contraindicates  the  use  of  the  anterior 
vaginal  route.     Practically  all  movable  ovarian  cystic  tumors  which 


POSTERIOR    VAGINAL    CELIOTOMY 


39 


Fig.  9. — Delivery  of  the  Uncut  Uterus  Through  the  Posterior  Vaginal 

Incision. 


A  long  posterior  speculum  and,  if  necessary,  two  side  retractors,  have  been  introduced  into 
the  peritoneal  cavity,  and  volsella  applied  to  successively  higher  points  on  the  posterior  wall  of  the 
uterus  have  brought  the  fundus  into  the  vagina.  The  fundus  when  lifted  up  toward  the  urethra 
exposes  the  anterior  wall  of  the  uterus  with  delivered  tubes  and  ovaries.  This  procedure  is  possible 
with  freely  movable  or  retrodeviated  uterus  with  loose  ligaments.  It  may  be  used  to  accomplish 
the  delivery  of  adnexa  or  ovarian  cysts  for  diagnosis  or  removal. 


POSTERIOR    VAGINAL    CELIOTOMY 


41 


Fig.  10. — Through  the  posterior  vaginal  incision  small  movable  ovarian  cysts  and  dermoids 
may  be  delivered  if  situated  in  the  cul  de  sac  of  Douglas  or  if  pushed  down  into  the  cul  de  sac  of 
Douglas  from  above.  It  is  generally  necessary  to  puncture  the  cyst,  to  grasp  the  edges  of  the 
incision  in  the  cyst  vi^all,  and  then  the  cyst  itself  with  long  forceps  and  thus  extract  the  collapsed 
tumor,  and  ligate  the  meso-ovarium  and  meso-salpinx  most  carefully  with  several  sutures.  It  is 
occasionally  necessary  to  deliver  the  uterus  itself  through  the  posterior  incision  in  order  to  bring  the 
tumor  within  reach  of  puncture  or  to  bring  the  pedicle  or  meso-ovarium  within  reach  of  the 
needle  or  ligature  carrier. 


l^OSTKRIOR    YAC.ISAL    CKMOTOMY 


43 


Fig.  1 1 . — The  transverse  incision  into  the  cul  de  sac  of  Douglas  may  be  sewed  in  the  direction 
of  the  incision  by  interrupted  sutures,  the  needle  being  passed  through  the  peritoneum  from 
below  upward,  taking  firm  hold  on  the  uterus  at  the  peritoneal  reflection.  The  incision  in 
the  posterior  fornix  is  then  closed  in  the  same  manner.  If,  in  any  case,  drainage  by  a  wick  of 
gauze  is  desired,  it  may  be  placed  between  any  two  interrupted  sutures. 


POSTERIOR   VAGINAL    CELIOTOMY 


45 


Fig.  12. — The  transverse  incision  may  be  sewed  in  the  longitudinal  direction  especially  in  the 
case  of  shallow,  angular  posterior  fornix  or  of  posterior  parametritis.  The  transverse  incision 
followed  by  thorough  separation  of  the  subperitoneal  connective  tissue  before  the  cul  de  sac  is 
opened  plus  the  longitudinal  sewing  of  the  incisions,  increases  the  mobihty  of  the  uterus  in  cases 
of  retrodisplacement  due  to  posterior  parametritis  or  to  sclerosis. 


POSTF.RIOR    VAGIN'AL    CELIOTOMY  47 

can  ])c  pushed  down  (\l'v\)  into  the  jjclvis  may  be  removed  by  the 
posterior  route  with  or  ^\■ithout  delivery  of  the  uterus.  The  cyst 
wall  is  pierced  with  a  trocar  or  f(jrceps,  and  after  the  iluid  or  dermoid 
contents  have  been  discharged  the  edges  of  the  incision  in  the  cyst 
wall  are  grasped  and  the  collapsed  tumor  is  extracted.  The  same 
holds  true  of  movable  dermoid  cysts  not  situated  lateral  or  antero- 
lateral to  the   uterus.     (Fig.  lo.) 

For  Posterior  Parametritis  and  Retrodisplacement. — The 
transverse  incision  into  the  Douglas  cul  de  sac  is  also  of  great  value 
where  an  old  sclerosing  posterior  parametrium  has  pulled  the  uterus 
into  retrodisplacement.  Incisions  into  the  posterior  peritoneal  sac 
are  sewed  as  a  rule  in  the  direction  in  w^hich  they  have  been  made 
(Fig.  ii).  In  these  cases,  however,  a  wide  transverse  incision  into  the_ 
cul  de  sac  of  Douglas  permits  the  peritoneal  and  vaginal  incisions  to 
be  sewn  in  a  longitudinal  direction  and  this  makes  the  uterus  more 
mobile  (Fig  12).  This  is  an  important  adjunct  to  any  operation  de- 
signed to  bring  forward  the  fundus  in  such  a  retrodisplaced  case. 

For  Drainage. — In  many  instances  after  abdominal  laparotomy 
or  after  anterior  celiotomy  packing  is  desired  because  of  raw,  oozing 
surfaces,  or  drainage  is  needed  because  of  infection  of  the  peritoneum 
or  injury  to  intestine,  etc.,  and  then  this  may  be  accomphshed,  and 
the  gauze  drawn  out  or  introduced,  through  the  posterior  incision. 
The  ascites  of  abdominal  tuberculosis  or  that  due  to  papilloma  or 
carcinoma  of  the  ovaries  or  in  some  cases  to  fibroma  of  the  ovary 
may  be  readily  drained  by  posterior  vaginal  incision. 

For  Pelvic  Abscess. — The  posterior  route  has  been  used  for 
years  in  the  opening  of  pelvic  abscesses.  Strictly  speaking,  this  is 
not  always  celiotomy,  for  in  a  certain  proportion  of  cases  the  pus  is 
not  in  the  peritoneal  cavity,  but  in  the  pelvic  connective  tissue,  posterior 
or  lateral  to  the  uterus.  In  the  vast  majority  of  cases  of  large  pyosal- 
pinges  and  tubo-ovarian  abscesses  opened  per  vaginam,  adhesions 
in  the  cul  de  sac  of  Douglas   practically   wall  oft'  the  pus  foci  and 


48  VAGINAL   CELIOTOMY 

pus  sacs  from  the  peritoneal  cavity.  The  posterior  route  is  of  course 
of  value  in  the  treatment  of  pelvic  peritonitis  according  to  the  method 
of  Pryor. 

Exudates  or  accumulations  posterior  or  postero-lateral  to  the 
uterus  consist  of  blood  or  inflammatory  exudate.  Blood,  inflammatory 
exudate,  pus,  may  be  in  the  cul  de  sac  of  Douglas  proper,  or  in  the 
tubes  or  ovaries  prolapsed  into  the  cul  de  sac  or  lateral  to  it,  or  may 
be  in  the  broad  hgaments;  exudate  or  pus  may  be  in  the  connect- 
ive tissue  under  the  cul  de  sac  of  Douglas,  i.  e.,  in  the  posterior 
parametrium . 

In  many  instances  one  is  not  certain  whether  he  is  dealing  with  a 
posterior  parametritis  or  an  encapsulated  purulent  exudate  in  the 
peritoneal  cavity,  or  with  pyosalpinges  or  tubo-ovarian  abscess,  or 
an  infected  hematocele. 

The  method  of  posterior  incision  is  of  great  value  in  the  presence 
of  retrouterine  accumulations,  not  alone  for  the  purpose  of  diagnosis 
but  for  the  purpose  of  treatment.  If  doubt  exists  as  to  the  diagnosis 
between  hematocele  and  posterior  parametritis,  if  the  exudate  lies 
directly  behind  the  uterus  and  extends  more  or  less  to  either  side, 
this  posterior  incision  is  of  great  value  in  making  a  diagnosis  as  well 
as  in  carrying  out  the  treatment.  In  these  cases  a  transverse  incision 
is  made  in  the  posterior  fornix  over  the  most  bulging  part  of  the  mass 
(Fig.  13).  It  is  always  advisable  to  make  this  incision  close  to  the 
cervix,  and  not  to  use  too  long  a  speculum.  When  the  cervix  is  lifted 
up  the  mass  remains  visible  if  we  are  dealing  with  a  posterior  para- 
metritis, whereas  in  the  case  of  pus  accumulations  in  the  tubes  and 
ovaries,  the  act  of  pulling  on  the  cervix  makes  the  mass  less  distinct. 
Hence  the  speculum  should  not  be  too  long  nor  should  the  cervix  be 
pulled  down  too  firmly.  A  transverse  incision  is  made  with  the 
scissors  and  then  a  long  pair  of  curved  scissors  is  pushed  directly 
into  the  mass  through  this  incision,  the  tip  of  scissors  always  pointing 
upward  toward  the  uterus  to  avoid  the  rectum.     The  handles  of 


POSTERIOR    VAOINAL    OELTOTOMY 


49 


Fig.  13. — Shows  to  an  exaggerated  extent  the  bulging  of  the  posterior  fornix  produced  by  a 
posterior  parametric  abscess.  The  same  condition,  but  to  a  less  pronounced  degree,  occurs  with 
an  intraperitoneal  or  intratubal  collection  of  pus  when  situated  in  the  cul  de  sac  of  Douglas.  The 
dotted  line  shows  the  position  and  extent  of  the  transverse  incision  through  the  mucosa  which  is 
to  be  made  with  scissors,  before  the  pus  accumulation  is  perforated  and  opened. 


P0STI;R!()R    VAGI\y\L    C:KrJOTOMY 


51 


Fig.   14. — Shows  the  introduction  of  a  long,  narrow,  not  too  sharp-pointed,  slightly  curved 
scissors  through  the  transverse  incision  of  figure  13  into  the  mass  in  the  posterior  fornix  with 
.  opening  of  the  scissors  and  stretching  of  the  vaginal  incision.     This  gives  free  outlet  to  the  pus. 
Scissors  or  long  dressing  forceps  are  the  only  instruments  used  by  the  author  in  entering  and  open- 
ing pelvic  abscesses. 


POSTERIOR  VAGINAL  CELIOTOMY  53 

the  scissors  arc  then  separated  and  the  resulting  discharge  of  either 
pus  or  Ijlood  makes  the  diagnosis  (Fig.  14).  If  blood  appears,  this 
may  be  drained  and  then  the  choice  of  route  for  attacking  the  ectopic 
gestation  rests  between  the  anterior  vaginal  incision  or  the  abdominal 
one,  unless  the  hematocele  be  an  old  infected  one,  when  it  may  be 
advisable,  temporarily  or  otherwise,  to  treat  the  condition  only  vaginally 
by  drainage. 

In  many  instances,  even  after  a  so-called  pelvic  abscess  is  opened, 
especially  when  situated  in  the  median  line,  one  is  not  sure  as  to  whether 
he  has  l^een  dealing  with  the  posterior  parametrium  or  a  purulent 
encapsulated  accumulation  in  the  cul  de  sac  of  Douglas,  or  pus  held 
within  the  tube  or  ovary,  i.e.,  pyosalpinx  or  tubo-ovarian  abscess. 
Hence  it  is  important  after  opening  such  abscesses  to  go  in  with  the 
finger,  to  enlarge  and  open  up  the  various  foci,  to  push  in  an  upward 
direction  with  great  care.  If  we  are  dealing  with  a  posterior  para- 
metritis, we  should  avoid  piercing  the  cul  de  sac  of  Douglas;  if  dealing 
with  any  of  the  other  inflammatory  conditions  mentioned,  we  should 
avoid  perforating  either  the  upper  lymph  wall  of  the  peritoneal  pus  ac- 
cumulations or  the  upper  walls  of  the  tubo-ovarian  pus  sacs  themselves. 

^Irrigation  of  resulting  cavities  should  be  of  the  very  mildest 
character,  carried  out  without  any  pressure;  often  no  irrigation  is 
advisable.  Subsequent  drainage  may  be  carried  out  by  the  use  of 
large  rubber  tubes,  which  must  then  be  sewn  to  the  edge  of  the  vaginal 
incision,  or  by  thorough  but  gentle  packings  of  gauze,  or  by  a  combina- 
tion of  the  two.  I  must  confess  to  a  preference  for  gauze,  for  by  this 
means  one  may  thoroughly  fill  out  the  entire  cavity.  The  use  of 
gauze,  however,  necessitates  frequent  changes,  each  time  a  little  less 
gauze  being  introduced,  in  order  to  prevent  new  foci  from  being 
formed  by  contact  of  the  walls  of  this  pus  cavity.  This  demands 
frequent  attention  on  the  part  of  the  surgeon,  more  so  than  if  tubes 
are  used,  but  I  find  the  excellent  results  well  worth  this  extra  labor. 

In  pus  accumulations  postero-lateral  to  the  uterus,  or  posterior 


54  VAGINAL   CELIOTOMY 

to  the  broad  ligaments,  the  posterior  fornix  incision  enables  us  to 
push  the  peritoneum  of  the  cul  de  sac  of  Douglas  upward  and  to 
dissect  it  off  laterally  and  then  with  the  introduced  finger,  aided  by 
manipulation  of  the  external  hand  held  on  abdomen,  to  perforate  pus 
sacs  without  entering  the  free  peritoneal  cavity. 

A  Step  in  Vaginal  Hysterectomy. — Posterior  vaginal  section 
is  an  essential  preliminary  to  practically  all  the  operations  for  the 
vaginal  removal  of  the  uterus.  Whenever  possible  the  posterior 
incision  should  enter  into  the  peritoneum  as  the  first  step  of  the  opera- 
tion. There  are  cases  where  this  is  not  possible,  the  cul  de  sac  of 
Douglas  coming  into  reach  only  after  the  cervix  and  lower  part  of  the 
uterus  have  been  freed  from  their  connections,  after  which  it  may 
be  possible  to  enter  the  posterior  peritoneum.  If  the  uterus  is  to 
be  split  through  the  posterior  wall  alone,  or  if  both  walls  are  to  be 
split  at  the  same  time  it  is  always  advisable  to  first  enter  both  the 
posterior  and  anterior  cul  de  sacs  when  feasible. 

Some  surgeons  practise  direct  entrance  into  the  posterior  cul  de 
sac  in  splitting  the  posterior  wall  of  the  cervix  and  uterus  from  the 
external  os  to  the  fundus.  They  enter  the  peritoneal  cavity  in  the  pro- 
cess of  splitting  the  cervix  without  the  aid  of  a  transverse  incision  into 
the  posterior  fornix.  This  procedure  constitutes  the  preliminary 
to  Doderlein's  method  of  vaginal  hysterectomy  (Figs.  7  and  8). 

In  this  method  the  portio  vaginalis  is  hfted  up  toward  the  symphysis, 
a  posterior  longitudinal  incision  is  made  which  splits  the  posterior 
lip  of  the  cervix  up  to  the  fornix.  The  splitting  is  continued  through 
the  peritoneum  of  Douglas  into  the  cul  de  sac  of  Douglas,  and  this 
peritoneum  is  grasped  and  sewed  to  the  edge  of  the  posterior  vaginal 
incision  (Fig.  8).  Laterally  two  or  three  sutures  are  applied  to  unite 
the  peritoneum  over  the  entire  wound  edge  under  which  lies  the  rectum. 
The  posterior  wall  of  the  uterus  is  then  drawn  down  by  tenaculum 
forceps  applied  to  both  sides  of  the  uterus  and  sphtting  is  continued 
between  these  forceps  (Fig.  15).     If  myoma  nodules  are  encountered. 


POSTERIOR    VAGINAL    CKLIOTOMY 


55 


Fig.  15. — The  uterus,  after  preliminary  splitting  of  the  posterior  wall  of  the  cer\dx  has  made 
entrance  into  the  cul  de  sac  of  Douglas,  is  divided  still  further.  A  posterior  speculum  is  intro- 
duced into  the  peritoneal  cavity  and  the  uterus  is  drawn  out  by  successively  applied  volsella  and 
the  splitting  is  continued  up  toward  the  fundus.  This  process  is  continued  so  that  when  the  uterus 
has  been  delivered  beyond  the  vuha  the  anterior  wall  seen  in  figure  9  is  also  to  be  divided. 

The  splitting  in  figures  7  and  8  is  continued  with  delivery  of  the  uterus  through  the  posterior 
incision.  This  represents  the  important  step  in  vaginal  hysterectomy  as  practised  by  Doderlein. 
After  delivery  of  the  completely  divided  uterus,  with  or  without  enucleation  of  any  myomata 
which  are  present,  the  remainder  of  the  operation  is  carried  out  by  clamps  and  ligation  or  by 
ligation  alone. 


ANTICRIOR    VAC.INAL    (VKIJ(JT(J.M Y  57 

these  are  ^^ras])ed  independently  by  v(jlsella,  enucleated  or  made  smaller 
by  cutting  out  wed.Gje-shaped  pieces,  until  the  remainder  of  the  uterus 
may  be  extracted.  The  uterus  is  then  split  further  up  (jver  the  fundus. 
The  bladder  remains  far  behind,  so  that  finally  only  a  small  bridge 
remains  between  the  anterior  fornix  and  the  base  of  the  vesicouterine 
phca.  The  anterior  wall  of  the  cervix  is  divided  up  to  the  antecervical 
connective  tissue  and  the  plica  is  united  to  the  anterior  fornix.  The 
two  divided  halves  of  the  uterus  are  then  freed  up  to  their  lateral 
connections,  and  these  may  be  divided  after  applying  strong  clamps 
to  the  ligaments.  The  blood  vessels  appearing  in  the  stumps  held 
in  the  clamps  are  tied,  and  then  the  clamps  may  be  removed  and 
the  stumps  may  be  covered  with  the  peritoneum. 

Doderlein,  however,  prefers  to  tie  off  the  ligamentum  suspensorium 
ovarii  and  the  pars  cardinalis  of  the  ligamentum  latum  in  sections 
before  cutting  them.  The  wound  surface  is  then  covered  with  the 
peritoneum. 


ANTERIOR  VAGINAL  CELIOTOMY. 

Anterior  colpoceliotomy  was  first  recommended  theoretically 
by  Sanger  in  1888. 

Sanger  said,  "we  may  obtain  a  direct  action  on  the  previously 
anteverted  corpus  uteri  through  transverse  separation  of  the  anterior 
vaginal  roof,  by  opening  of  the  plica  anteriorly  and  fixation  of  the 
corpus  uteri  with  silver  thread  to  the  vagina;  the  wound  then  being 
united  longitudinally,  whereby  the  collum  at  the  same  time  is  forced 
backward  into  its  normal  position." 

For  a  long  time  the  operation  of  vaginal  fixation  was  performed  for 
the  correction  of  retroflexio  through  a  transverse  fornix  incision  and 
without  opening  the  peritoneum.  In  1890,  vaginal  laparotomy  was 
done  occasionally  by  Dlihrssen.  It  was  first  accidently  performed 
by  him;  the  peritoneal  fold  being  torn  on  grasping  the  anterior  wall 
of  the  uterus  in  the  course  of  a  vaginal  fixation  which  at  that  time 
was  done  without  opening  the  vesicouterine  fold.  The  same  accident 
occurred  to  Zweifel  and  Fritsch. 

In  November,  1890,  in  a  case  of  anteversion,  Dlihrssen  made 
a  transverse  opening  in  the  anterior  fornix,  grasped  the  uterus  with 
volsellum  which  tore  through  the  plica,  and  the  peritoneum  was 
opened.  The  uterus  was  pushed  forward  by  a  double  running  catheter 
introduced  into  the  uterus,  grasped  by  a  volsellum,  and  then  fixed 
to  the  vaginal  wall. 

In  a  second  case,  one  of  retroflexio,  the  peritoneum  was  opened 
and  the  soft  uterus  had  an  intrauterine  catheter  in  it  to  push  the 
fundus  forward.  It  perforated  the  uterus;  the  perforation  was  closed 
and  the  uterus  was  fixed  to  the  anterior  vaginal  wall  by  a  suture  passed 
through  the  uterus  above  the  tear. 

58 


A.NTKRIOR    \'A(;iNAL   CKIJOTOMY  59 

In  1892,  Diilirsscn  lx\<i;an  to  open  the  jjcritoneum  purposely. 

Kiistner  was  among  the  iirst  to  purposely  make  a.  wide  incision 
in   the  peritoneal   fold. 

In  1893,  Diihrssen  removed  a  fibroma  from  the  anterior  uterine 
wall  by  a  va,<j^inal  celiotomy.  About  the  same  time  he  removed  the 
adnexa  by  this  route.  After  adopting  this  method,  he  added  to  the 
transverse  vaginal  incision  a  longitudinal  incision  of  2-4  cm.,  such 
an  incision  having  been  recommended  by  Zwiefel.  He  said  in  1894, 
that  he  did  this  because  the  vagina  was  narrow  and  the  tumors  were 
large. 

Diihrssen's  earliest  cases  of  vaginal  fixation  without  opening  the 
plica  were  done  through  the  transverse  incision.  After  he  began  to 
open  the  plica  he  practised  extraction  of  the  corpus  and  adnexa.  A 
transverse  incision  was  made  and  the  uterus  was  drawn  down  by  two 
ligatures  until  the  plica  could  be  opened.  Then,  after  removing 
the  volsella  and  the  speculae  and  pushing  the  portio  back,  the  corpus 
was  drawn  into  the  fornix  by  the  aid  of  the  uppermost  provisional 
suture  and  then  with  the  aid  of  volsella  put  on  still  higher  the 
entire  uterine  body  was  drawn  into  the  vagina  and  out  to  the  vulva. 

Then  he  found  it  necessary  to  make  the  vaginal  wound  larger, 
as  it  also  aided  in  replacing  the  uterus.  He  therefore  added  a  2-4 
cm.  longitudinal  incision. 

In  1893,  Diihrssen  began  the  regular  use  of  vaginal  celiotomy, 
although  up  to  the  end  of  1894  anterior  colpoceliotomy  was  mainly 
practised  for  the  purpose  of  vaginal  fixation,  and  even  then  the  opening 
of  the  vesicouterine  peritoneal  fold  in  the  hands  of  most  operators  was 
generally  accidental. 

Kiistner  opened  the  plica  widely,  using  a  simple  longitudinal  inci- 
sion and  fastening  the  corpus  with  two  or  three  silkworm  sutures  to  the 
anterior  vaginal  wall. 

Martin  did  the  same. 

In  1894,  ^Martin  recommended  the  method  of  anterior  celiotomy  for 


6o  VAGINAL   CELIOTOMY 

the  enucleation  of  myomata.  In  1895,  he  advised  this  method  for 
the  removal  of  adnexa.  Among  others,  Kossmann  wrote  considerably 
in  favor  of  anterior  celiotomy. 

In  1895,  Diihrssen  reported  two  ectopic  gestations  removed  through 
the  vagina,  and  later  recorded  the  removal  of  large  ovarian  cysts  and 
pus  tubes.  About  this  time  he  improved  the  technic  of  the  operation 
in  order  to  avoid  disturbances  in  labor  which  followed  the  operation  of 
vaginal  fixation.  This  consisted  in  sewing  the  vesicouterine  fold  before 
tying  the  sutures  which  fixed  the  uterus  to  the  vagina.  The  resulting 
" sero-serose "  peritoneal  union  prevents  dystocia  in  labor.  In  1895, 
Wertheim  reported  the  enucleation  of  fibromata  by  the  vaginal  route. 
Fehling  and  Peter  Miiller  recommended  anterior  and  posterior  colpor- 
rhaphy  plus  vaginal  fixation  for  the  treatment  of  prolapse  of  the  uterus. 

In  1896,  Wertheim  and  others  devised  vaginal  fixation  of  the  round 
ligaments  and  shortening  of  the  round  ligaments  through  vaginal  celi- 
otomy to  avoid  the  disturbances  in  labor  which  had  followed  some 
cases  of  vaginal  fixation. 

Schauta  early  adopted  the  method  of  vaginal  celiotomy  for  the 
performance  of  ovariotomy.  He  was  the  first  to  use  the  vaginal  route 
for  the  removal  of  large  cystic  tumors  of  the  adnexa,  cysts  containing 
from  ten  to  fifteen  quarts  of  fluid.  He  said  that  ovariotomy  is  easily 
done  through  the  vagina  if  the  cyst  is  movable  and  pedunculated. 
Even  if  only  a  small  part  of  the  cyst  surface  can  be  reached,  it  can 
readily  be  punctured  by  a  trocar.  The  cyst  wall  thus  opened  is  pulled 
through  the  vaginal  incision,  the  pedicle  is  tied,  and  the  cyst  removed. 
There  is  room  enough  for  this  procedure  even  with  large  cysts  in  which 
the  lower  pole  of  the  tumor  does  not  dip  down  into  the  pelvis.  In  that 
event,  the  lower  pole  can  be  reached  through  the  peritoneal  incision 
by  introducing  two  fingers  into  the  peritoneal  cavity,  on  which  the 
trocar  can  be  pushed  into  the  cyst,  which  can  then  be  drawn  down, 
after  being  emptied.  Schauta,  in  his  operations,  removes  dermoid  and 
also  multilocular  cysts ;  one  compartment  after  another  is  emptied  by 


ANTERIOR    \'A(;i.\AL    ClvIJOTOMY  6l 

the  trocar  so  that  unilocular  cysts  arc  not  the  only  ones  adajjtcd  to  this 
method. 

In  1896,  Wcrtheim  reported  the  vaginal  extirpation  of  intraliga- 
mentous cysts.  Theoretically  speaking,  it  is  not  necessary  to  enter  the 
|)eritoneal  ca\'ity.  The  lower  pole  of  the  cyst  is  exposed  through  the 
vagina  and  emptied  by  puncture.  The  cyst  wall  is  then  shelled  out 
from  its  subperitoneal  situation.  In  his  first  case  the  cyst  extended 
to  the  ensiform  cartilage  and  contained  ten  c|uarts  of  fluid.  It  was 
remarkable  with  what  ease  the  cyst  was  shelled  out  in  toto  without  any 
bleeding.  In  this  instance  the  uterus  was  also  removed  because,  as  is 
often  the  case  with  large  intraligamentous  cysts,  it  was  pressed  flat 
and  misshaped  through  pressure.  His  second  case  was  a  cystic 
intraligamentous  tumor  of  the  ovary  the  size  of  a  child's  head.  It  was 
peeled  out,  as  was  the  first  case,  but  tore  in  several  places  where  it  was 
firmly  adherent  to  the  peritoneal  covering.  Its  removal  was  not  entirely 
extraperitoneal. 

Chrobak  has  also  removed  intraligamentous  cysts  in  this  manner, 
and  found  that  it  might  be  advisable  to  leave  in  situ  those  parts  of  the 
cyst  wall  which  could  not  be  loosened  from  the  peritoneum,  and  to  sew 
them  into  the  vagina.  He  remarked  also  that  in  abdominal  operations 
it  was  sometimes  necessary  to  leave  behind  areas  of  cyst  wall  too  closely 
connected  to  intestine. 

Before  this  period  vaginal  hysterectomy  for  double  pyosalpinx, 
especially  with  the  aid  of  clamps,  was  being  practised  in  France  and 
Germany,  and  was  brought  to  a  high  state  of  perfection  by  Landau  of 
Berlin. 

Chrobak  began  vaginal  extirpation  of  myomata  in  1892,  and 
by  1894  had  done  seventy  vaginal  myomotomies.  "It  is  not  always 
possible"  he  says,  "to  say  whether  the  operation  can  be  finished 
through  the  vagina.  In  all  cases,  preparation  for  a  laparotomy  must 
be  made." 

Boldt's  use  of  the  vaginal  route  for  hysterectomy  dates  back  to  1887. 


62  VAGINAL   CELIOTOMY 

In  1 89 1  he  began  vaginal  operations  on  a  larger  scale  with  a  view  to 
studying  the  merits  of  that  route.  He  employed  the  method  of  vaginal 
hysterectomy  for  fibroids  and  advised  the  use  of  the  vaginal  route 
wherever  possible.  He  was  first  in  this  country  to  try  vaginal  fixation 
for  the  correction  of  retroversion.  In  1895  he  reported  a  tubal 
gestation  removed  per  vaginam. 

Goffe  early  adopted  the  use  of  the  vaginal  route.  He  practises  it 
now  in  the  following  conditions:  (i)  Retroflexion  and  descent  of  the 
uterus.  (2)  Retroversion  with  adhesions,  which  he  treats  by  shorten- 
ing, the  round  ligaments;  if  the  adhesions  are  deep  down  in  the  cul  de 
sac  of  Douglas,  he  separates  these  through  a  posterior  vaginal  incision. 
(3)  Conservative  operations  on  the  adnexa.  (4)  Pyosalpinx,  ectopic 
gestation,  dermoid  cysts  of  the  ovary.  (5)  Myomectomy  for  small 
fibroids.  (6)  Hysterectomy  for  many  cases  of  fibroids.  (7)  For  the 
correction  of  certain  cases  of  sterility  (which  really  comes  under  class 
three). 

In  a  publication  which  appeared  in  1899,  Diihrssen  reported  500 
operations  by  anterior  vaginal  cehotomy  and  indicated  the  class  of 
cases  in  which  this  method  could  be  used.  The  indications,  exclusive 
of  those  for  hysterectomy,  were  (i)  Movable  retroflexion  and  retro- 
version. (2)  Fixed  retroflexion.  (3)  Inflammations  and  perforations 
of  the  uterus.  (4)  For  benign  tumors  of  the  uterus.  (5)  For  diseases 
of  the  adnexa.  (6)  For  solid  tumors  of  the  ovary,  if  they  are  no  larger 
than  a  fist.  (7)  For  ectopic  gestation.  (8)  For  small  or  even  large  cystic 
tumors.  (9)  For  the  purpose  of  producing  artificial  sterility  by  hgat- 
ingorexsecting  parts  of  the  Fallopian  tubes.  (10)  Forcystocele.  (11) 
For  hgamentous  parovarian  cysts,  if  they  are  free  of  the  pelvic  wall. 

The  advantages  according  to  Diihrssen  are,  (i)  the  absence  of 
an  abdominal  scar;  freedom  from  the  danger  of  hernia  or  fistula; 
freedom  from  the  possibility  of  painful  adhesions  of  the  omentum 
or  intestine  to  the  line  of  incision;  freedom  from  the  use  of  an 
abdominal  binder;  (2)  few  subjective  annoyances  immediately  after 


ANTERIOR    VA(;]Ny\L   VVAAOTOMY  63 

the  operation;  (3)  rapid  convalescence  and  (|uiclv  restoration  to 
health  and  ability  to  work;   (4)  low  mortality. 

The  great  claim  made  for  the  vaginal  method  is,  that  it  is  less 
dangerous  and  that  the  statistics  as  regards  mortality  are  better.  It 
is  a  question  whether  this  claim  can  be  substantiated  t(j  the  degree 
claimed  by  its  adherents.  By  1906,  Diihrssen  had  performed  1600 
cases  of  vaginal  celiotomy  with  a  mortality  of  but  2  per  cent.  He 
states  that  only  in  20  per  cent,  of  all  cases  is  it  necessary  to  open  the 
abdominal  cavity  and  emphasizes  his  claim  that  80  per  cent,  of  all 
gynecological  diseases  in  which  opening  of  the  peritoneum  is  necessary 
can  be  healed  without  ventral  incision.  He  states,  among  other  things, 
that  the  mortality  is  less,  restoration  to  health  quicker,  after  vaginal 
celiotomy  and  that  postoperative  exudates,  if  they  do  form  after  the 
removal  of  pus  adnexal  tumors,  generally  break  through  of  their  own 
accord  into  the  vagina  after  vaginal  cehotomy. 

When  we  take  into  consideration  that  reported  vaginal  operations 
include  very  many  cases  of  retroflexion,  that  many  of  the  inflammatory 
involvements  of  the  adnexa  are  not  of  severe  grade,  that  the  severe 
cases  of  pyosalpinx  give  much  better  prognosis  because  the  uterus 
is  also  removed,  we  see  how  unfair  the  comparison  is. 

If  we  exclude  the  cases  of  vaginal  fixation,  the  vast  majority  of 
which  are  done  primarily  for  the  retroflexion  alone,  we  have  a  mortality 
of  5  to  8  per  cent.  It  can,  therefore,  be  seen  that  the  severity  of  the 
cases  and  the  manner  in  which  the  statistics  are  compiled  have  a 
decided  bearing  on  the  reported  mortality. 

It  is  fairly  claimed,  however,  that  such  operations  as  may,  with 
relative  freedom  from  marked  adhesions,' be  done  through  the  vagina 
show  a  mortality  in  all  probability  somewhat  lower  than  cases  operated 
upon  by  the  abdominal  route. 

Diihrssen  stated  in  1899  that  the  conditions  essential  to  the  ready 
performance  of  vagiiiat  celiotomy  were:  (i)  the  uterus  must  be  one 
that  can  be  well  pulled  down;  (2)  tumors  must  not  be  larger  than  a 


64  VAGINAL   CELIOTOMY 

fist;  (3)  extensive  internal  adliesions,  especially  with  intraligamentous 
or  pseudo-intraligamentous  tumors,  must  be  absent. 

Diihrssen  further  stated  that  in  diseases  of  the  adnexa  vaginal 
celiotomy  was  contraindicated :  (i)  With  severe  perimetritic  adhesions 
high  up  or  when  the  tube  and  ovaries  are  not  palpable  in  inflammatory 
conditions,  this  meaning  that  they  are  probably  deeply  or  laterally 
fixed  or  covered  by  adhesions  of  intestine,  omentum  or  sigmoid.  (2) 
In  chronic  oophoritis  or  perioophoritis,  where  the  ovary  is  adherent 
close  to  the  lateral  pelvic  wall.  '(3)  In  large  tumors  of  the  adnexa 
closely  adherent  to  the  lateral  pelvic  wall;  these  are  frequently  the 
so-called  tubo-ovarian  tumors.  (4)  If  tumors  of  the  adnexa  are  situated 
high  up  toward  the  abdominal  cavity  or  situated  anteriorly  and  united 
to  the  bladder,  or  if  there  is  tuberculosis  of  the  tubes.  In  the  latter 
cases  there  are  many  adhesions  to  the  intestine  and  bladder,  and 
there  is  a  very  thick,  brittle  mesosalpinx,  there  is  a  short  ligamentum 
suspensorium  ovarii. 

Continued  practice  and  experience  have  led  Diihrssen  to  extend  the 
limitations  of  the  vaginal  method,  so  that  he  finds  vaginal  cehotomy  indi- 
cated even  in  many  cases  included  under  the  four  headings  above.  Per- 
sonally, I  believe  the  contraindications  quoted  above  are  legitimately 
founded.  However,  the  following  views  of  Abel  and  Schauta  show  to 
what  extent  the  vaginal  method  is  practised  and  the  statement  of  Chro- 
bak  shows  how  thoughtfully  the  problem  of  choice  should  be  considered. 

Abel  acknowledges  that  abdominal  operations  are  easier  than 
vaginal,  and  states  that  his  early  objection  to  the  vaginal  route  was 
due  to  the  fact  that  he  did  not  understand  the  method.  The  con- 
ditions in  which  there  is  a  choice  between  the  vaginal  and  abdominal 
route  in  his  opinion  come  under  the  headings  of  (i)  displacements 
of  the  uterus;  (2)  tumors  of  the  ovary;  (3)  inflammatory  tubal  con- 
ditions; (4)  tubo-ovarian  inflammations;  (5)  tubal  gestations;  (6) 
myomata.  He  believes  that  all  ovarian  tumors  should  be  removed 
through  the  vagina,  except  very  large  cystic  tumors,  large  solid  tumors, 


ANTKRKJR    YACASAl.    (  M.IGTOMY 


65 


ri^s^; 


Fig.  16. — Original  simple  transverse  incision  of  Diilirssen,  with  bladder  dissected  back 
from  cervix  and  uterus  by  gauze-covered  index  finger.  The  finger  palpates  the  vesico-uterine 
plica  and  can  draw  it  down  into  view  if  a  narrow  anteri(jr  retractor  is  introduced  as  above. 


ANTERIOR    VAGINAL   CELIOTOMY 


67 


Fig.  17. — Old  method  of  separating  bladder  from  its  vagino-uterine  connection  by  simple 
longitudinal  incision,  begun  by  dissection  of  vaginal  wall  from  bladder.  Then  the  bladder  is  to 
be  picked  up  at  the  lower  end  of  the  incision,  and  is  to  be  separated  from  its  union  to  the  cervi.x 
and  uterus  bv  blunt  dissection. 


ANTI'IRIOR    \A(;i\AL    ("KLIOTOMY  69 

and  carcinomatous  tumors  of  the  ovary,  rntrali.^amentous  tumors 
and  tumors  with  twisted  pedicles,  which  lUlri^er  says  should  he  done 
through  the  aljdomen,  Abel  does  through  the  vagina.  For  Abel, 
adhesions  are  no  contraindications.  They  must  be  extremely  extensive 
he  says,  to  furnish  an  ol^stacle  which  cannot  be  overcome  by  the 
vaginal  route.  Size  is  no  obstacle  so  long  as  the  ovarian  tumors 
are  cystic,  says  Abel.  He  finds  the  removal  of  small  cystic  tumors 
to  be  without  danger.  The  vaginal  operation  for  larger  and  compli- 
cated cystic  tumors  is  less  dangerous,  and  the  same  holds  good  in 
the  case  of  dermoid  cysts.  He  advises  the  abdominal  method  only 
for  exceptionally  large  cystic  tumors,  for  large  solid  tumors  and  for 
carcinomatous  grov^ths  of  the  ovary.  He  further  says,  "He  who 
can  control  the  vaginal  method  to  the  greatest  possible  degree  can, 
by  niorceUement,  vaginally  remove  fibroid  tumors  which  are  scarcely 
considered  possible."  "It  is  not  right  to  say  that  only  myomata 
which  extend  to  the  umbilicus  should  be  attacked  vaginally  and  that 
larger  tumors  should  be  removed  abdominally.  This  depends  upon 
the  size  of  the  vagina,  the  motility  of  the  tumor  and  the  skill  of  the 
operator.  There  is  no  doubt  that  the  vaginal  operation,  even  if  it 
lasts  longer,  because  of  a  protracted  morcellement,  constitutes  a  much 
less  dangerous  attack  than  the  abdominal  operation." 

Schauta  says,  "It  is  self-evident  that  the  vaginal  operation  demands 
greater  skill  and  experience  than  the  abdominal."  He  is  continually 
astonished  how  simple  abdominal  laparotomy  now  seems  to  him, 
in  comparison  with  the  vaginal  operation.  "It  is  natural  that  every 
operator  should  begin  with  laparotomy  and  then  adopt  the  vaginal 
mode  of  operation.  The  reverse  is  scarcely  possible.  This  is  mainly 
the  case  because,  without  doubt,  the  vaginal  operation  gives  better 
statistics  than  laparotomy  and  because  it  show^s  a  smaller  mortality. 
One  can  readily  claim  that  an  operation  according  to  the  vaginal 
method  is  also  less  dangerous  than  the  same  operation  by  means 
of    laparotomy."     We    must    always    compare  the  same  operations. 


70 


VAGINAL   CELIOTOMY 


That  injuries  also  occur  in  laparotomy  is  an  old  story.  With  Schauta, 
injuries  formerly  occurred  more  frequently  with  laparotomy  than  now 
by  the  vaginal  method.  "In  the  latter,  injuries  to  the  ureter  or  bladder 
occur  less  frequently  than  with  laparotomy.  That  in  the  latter,  too, 
intestinal  injuries  may  occur  without  being  recognized  is  weh-known. 
These  are  not  always  major  injuries;  often  they  are  not  recognized; 
the  serous  covering  is  simply  gone  at  a  certain  point.  Injury  to  the 
intestine  by  the  vaginal  method  is  less  dangerous  than  with  laparotomy. 
In  the  former,  intestinal  contents  follow  a  shorter  path  in  their  exit 
than  in  laparotomy.  The  vaginal  method  of  operation  should  not 
be  considered  in  a  spirit  of  enthusiasm,  but  calmly  and  coolly.  Wher- 
ever an  operation  can  be  carried  out  vaginally,  it  should  always  be 
done  by  this  method.  However,  everything  must  be  prepared  for 
a  laparotomy.  That  one  should  promise  a  patient  to  positively  and 
surely  complete  an  operation  by  the  vaginal  method  is  evidently 
out  of  question.  He  must  always,  in  all  cases,  leave  himself  free 
to  change  the  work  and  method  of  operation,  even  during  the  operation, 
in  case  this  proves  to  be  necessary." 

TECHNIC    OF    THE   NEW   METHOD  OF  ANTERIOR  COLPOCELIOTOMY. 

Among  the  first  to  do  vaginal  celiotomy,  for  other  purposes  than 
hysterectomy,  by  the  anterior  vaginal  route,  namely  through  separation 
of  the  bladder  and  incision  of  the  vesico-uterine  fold  of  the  peritoneum, 
were  Mackenrodt  and  Diihrssen,  who  chose  this  means  of  performing 
what  is  known  as  vagino-fixation.  The  early  operations  of  Dtihrssen 
were  done  mainly  through  a  transverse  incision  on  the  anterior  wall  of 
the  cervix  (Fig.  i6).  Later,  attention  was  paid  to  adding  a  long  lon- 
gitudinal incision.  Martin  and  others  practised  the  longitudinal  inci- 
sion alone  as  a  means  of  separating  the  bladder  and  thus  entering 
the  peritoneal  cavity  (Fig.  17).  Subsequently,  Diihrssen  and  others 
increased  the  extent  of  the  incisions  by  adding  a  longitudinal  incision 
to  the  transverse  one,  making  the  operation  of  vaginal  celiotomy  in- 


ANTl.RIOR    \A(;iNAL    CELIOTOMY  71 

linitcly  easier.  Separation  of  the  bladder  from  the  anterior  vaginal 
wall  was  first  practised  by  the  use  of  the  knife,  and  then  was  done  by 
many  with  the  aid  of  scissors,  which  procedure  leaves  a  very  oozing 
surface.  Aside  from  the  incisions  themselves,  which  should  be  made 
with  the  scissors,  the  separation  of  the  bladder  from  the  anterior 
vaginal  wall  is  readily  carried  out  with  the  aid  of  gauze,  while  the 
separation  of  the  bladder  from  the  anterior  wall  of  the  uterus  is  readily 
accomplished  with  the  aid  of  the  fingers  or  of  gauze.  The  important 
element  in  the  successful  carrying  out  of  vaginal  celiotomy  is  the  com- 
bination of  a  transverse  and  long  longitudinal  incision  with  a  thorough 
separation  of  the  bladder,  especially  at  its  lower  lateral  attachments 
to  the  cervix.  A  further  aid  to  the  successful  performance  of  the 
operation  is  the  use  of  specula  of  proper  lengths  and  widths,  so  that 
the  cervix  may  be  pulled  far  down  toward  the  vulvar  outlet,  or  pushed 
back  in  order  to  bring  the  fundus  forward. 

With  these  specula  the  bladder  is  held  up  out  of  danger,  permitting 
work  on  the  vesico-uterine  fold  of  peritoneum  and  with  the  insertion 
of  these  wide  fiat  specula  into  the  peritoneal  cavity  the  drawing  out 
of  even  a  large  uterus  is  rendered  easy,  and  exposure  of  nonadherent 
tubes  and  ovaries  is  made  a  relatively  simple  procedure. 

This  operation  is  divided  into  three  stages: 

1.  Separation  of  the  bladder  by  colpotomy.  (a)  From  cervix  and 
uterus;  (b)  from  anterior  fornix  and  anterior  vaginal  wall. 

2.  Opening  of  the  peritoneum. 

3.  Delivery  of  the  uterus. 

SEPARATION  OF  BLADDER  FROM  THE  CERVIX  AND  UTERUS. 

A  short  posterior  speculum  is  introduced  and  firmly  pressed  against 
the  posterior  vaginal  wall  and  the  perineum.  The  cervix  is  then  firmly 
grasped  by  one  or  two  volsella,  which  are  best  passed  through  both  an- 
terior and  posterior  lips.  By  firm,  steady  traction  the  cervix  is  brought 
as  close  to  the  posterior  wall  of  the  vulvar  outlet  as  possible.     A  wide 


72  VAGINAL   CELIOTOMY 

transverse  incision  is  then  made  with  a  pair  of  scissors  just  below  the 
margin  of  the  bladder,  the  incision  passing  well  through  the  mucosa  of 
the  vaginal  portion  of  the  cervix  down  to  the  wall  of  the  cervix.  Two 
artery  forceps  are  then  applied  to  the  upper  margin  of  the  incision  on 
either  side  of  the  exact  median  line  (Fig.  i8).  The  lower  part  or  base 
of  the  bladder  is  separated  by  firm  rubbings  of  the  gauze-covered  index 
finger  from  the  anterior  wall  of  the  cervix  (Fig.  20)  until  the  vesico- 
uterine fold  of  the  peritoneum  is  reached  (Fig.  16).  This  separation 
of  the  lower  edge  of  the  bladder  must  generally  be  begun  with  scis- 
sors in  nulliparae,  in  whom,  in  loosening  the  bladder,  it  is  usually 
necessary  to  cut  through  a  few  firm  bands  uniting  the  bladder  to  the 
cervix  (Fig.  19). 

Further  up  the  union  of  bladder  to  cervix  is  so  loose  that  the  sepa- 
ration is  readily  made  with  the  finger.  At  times,  however,  there  are 
firm  connections  more  especially  in  the  middle  area  than  toward  the 
sides  of  the  cervix  and  uterus.  The  smooth  peritoneal  plica  is  readily 
recognized  by  the  fingers,  and  can  be  drawn  down  and  grasped  with  a 
clamp.  The  union  of  the  peritoneum  to  the  posterior  wall  of  the  blad- 
der is  readily  separated  before  or  after  the  opening  of  the  pHca.  It  is 
better  that  the  fingers  should  now  continue  to  separate  the  posterior 
wall  of  the  bladder  from  the  peritoneum  which  forms  its  posterior  cov- 
ering, and  also  forms  the  anterior  wall  of  the  vesico-uterine  pouch. 
This  separation  should  be  carried  upward  for  at  least  a  distance  of  two 
or  more  inches  above  the  base  of  the  vesico-uterine  cul  de  sac. 

In  nulliparae,  after  separating  the  anterior  fornix  and  bladder  from 
the  cervix,  we  sometimes  find  a  thick  vesico-uterine  membrane  which 
cannot  be  perforated  by  the  finger  or  pushed  back  by  blunt  dissection. 
This  must  be  cut  through  before  we  reach  the  vesico-uterine  peritoneal 
fold.  This  membrane  may  be  grasped  by  two  forceps  and  cut  through 
with  scissors.  When  it  is  cut  through,  the  finger  passes  into  the  sub- 
peritoneal connective  tissue  and  we  find  the  smooth,  thin  vesico-uterine 
fold.     The  plica  is  smooth  and  pinkish-white  in  color  and  never  red. 


AX'llRIOR    VAOINAL    (  !•  I.IOTOMY 


73 


■  f'-^SKfeS^S 


i 


Fig.  iS. — The  lower  border  of  the  bladder  can  be  readily  fixed  by  introducing  a  sound  into 
the  bladder  and  noting  the  point  to  which  the  tip  of  the  sound  descends,  so  that  it  can  be 
readily  felt.  A  transverse  incision  is  made  with  a  pair  of  scissors  through  the  entire  width  of 
the  cervix  a  Uttle  below  the  lower  border  of  the  bladder.  Two  pairs  of  artery  forceps  are  then 
attached  to  the  median  area  of  the  upper  margin  of  this  incision.  By  pulling  up  on  these  forceps 
a  series  of  bands  which  form  the  attachment  of  the  bladder  to  the  anterior  wall  of  the  cervix  are 
brought  into  view. 


ANTERIOR    VA(;iNAL   CELIOTChMV 


75 


Fig.  19. — The  two  pairs  of  artery  forceps  which  have  grasped  the  upper  border  of  this  trans- 
verse incision  are  pulled  up  tightly,  and  a  short  pair  of  blunt-pointed,  curved  scissors  makes 
a  few  snips,  separating  the  larger  of  these  bands  which  unite  the  bladder  to  the  anterior  wall  of 
the  cervix.     The  tip  of  the  scissors  is  held  close  to  the  cervical  wall. 


ANTERIOR    \AC.I\AL    CIIJOTOMY  77 

If  in  doubt,  the  introduclion  of  a  sound  into  the  bladder  makes  the 
differential  distinction  from  the  l:)ladder. 

In  multipara',  the  anterior  fornix  and  bhidder  are  easily  separated 
from  the  cervix  by  l)lunt  dissection  with  the  finger  up  to  the  vesico- 
uterine ])eritoneum.  The  ])lica  can  be  felt  with  the  fingers  and  can  be 
drawn  down  into  the  field  of  vision  (Fig.  16)  and  caught  up  with  the  for- 
ceps. Separation  of  the  bladder,  if  carried  out  in  this  fashion  with  the 
aid  of  a  wide  transverse  incision,  avoids  injury  to  this  organ  or  to  the 
ureters.  The  separation  when  extended  well  laterally  so  as  to  free  the 
bladder  from  its  relation  to  the  lateral  border  of  the  cervix  and  uterus, 
makesligationof  the  uterine  arteries  without  injury  to  the  ureters  more 
certain.  Through  this  transverse  incision  alone  approach  to  the  vesico- 
uterine cul  de  sac  is  not  so  diflicult  in  multipara;  and  delivery  of  the 
uterus  can  be  carried  out.  However,  the  incision  is  not  sufficient  for 
thorough  work,  there  being  too  little  room  after  delivery  of  the  uterus, 
nor  can  the  peritoneal  fold  be  taken  hold  of  and  opened  in  a  careful 
surgical  manner.  Entrance  into  the  anterior  peritoneal  recess  should 
be  gained  under  control  of  the  eye,  and  tearing  into  this  peritoneal  area 
with  the  fingers  is  not  alone  unnecessary  but  is  contraindicated  in 
thos3  cases  where  it  is  desired  to  again  sew  the  peritoneal  incision,  or 
where  the  peritoneal  tissue  is  made  use  of  in  the  process  of  attaching 
th2  uterus  to  it.  The  means  of  increasing  the  extent  of  area  through 
which  work  is  best  done  involves  the  still  further  separation  of  the 
bladder,  and  therefore  the  still  further  removal  of  the  ureters  from 
their  intimate  relation  to  the  lateral  wall  of  the  uterus.  This  step, 
which  is  of  especial  value  in  the  performance  of  hysterectomy,  is  ac- 
complished by  the  next  incision,  the  longitudinal  incision  in  the 
anterior  vaginal  wall,  which  may  be  extended  from  the  transverse 
incision  upward  as  far  toward  the  urethra  as  is  desired. 


78  VAGINAL   CELIOTOMY 

SEPARATION  OF  BLADDER  FROM  ANTERIOR  FORNIX  AND  ANTERIOR 

VAGINAL  WALL. 

Through  separation  of  the  bladder  from  the  cervix  and  lower  part 
of  the  uterus  in  the  manner  just  described  the  bladder  generally 
retracts  upward,  so  that  a  longitudinal  incision  2  to  3  cm.  long  may 
be  made  in  the  anterior  fornix  at  right  angles  to  the  transverse  one 
before  the  lower  border  of  the  bladder  is  reached.  A  pair  of  long 
sharp-pointed  scissors  makes  a  slight  cut  in  the  vaginal  mucosa  between 
the  two  artery  forceps  (Fig.  21).  The  lower  blade  is  then  introduced 
under  the  vaginal  mucosa  between  it  and  the  attached  bladder,  and 
by  a  series  of  short  cuts  (Fig.  22),  the  vaginal  mucosa  is  incised  for  a 
distance  of  from  2  to  4  1/2  inches,  an  anterior  speculum  being  intro- 
duced to  draw  the  vaginal  mucosa  of  the  anterior  vaginal  wall  taut  if 
necessary.  With  the  first  pair  of  curved  round-ended  scissors,  a  slight 
snip  is  made  between  the  vaginal  mucosa  and  the  bladder  at  each 
corner  to  which  the  artery  forceps  is  attached  (Figs.  23-25).  Then 
with  the  aid  of  gauze  alone,  the  vaginal  mucosa  being  first  everted  by 
the  artery  forceps,  the  bladder  is  gradually  and  carefully  separated  from 
the  anterior  vaginal  mucosa  (Fig.  24),  throughout  the  entire  length  of 
the  longitudinal  incision. 

The  separation  of  the  bladder  at  the  lower  areas,  along  the  entire 
extent  of  the  transverse  incision,  should  be  carried  on  to  and  beyond 
the  lateral  margins  of  the  cervix  (Fig.  26).  Higher  up  the  separation 
can  be  carried  laterally  as  far  as  desired.  It  should  be  continued 
upward  so  that  the  bladder  is  separated  from  the  anterior  vaginal 
wall  for  at  least  1/2  inch  above  the  upper  point  of  the  longitudinal 
incision  (Fig.  27). 


Fig.  20. — The  attachment  of  the  bladder  to  the  anterior  cervical  wall  is  now  loosened  by  the 
index  finger  covered  with  gauze,  which  firmly  presses  against  the  anterior  wall  of  the  cervix  and 
pushes  its  way  upward  by  a  series  of  short,  steady  rubbings,  and  so  begins  the  separation  of  the 
bladder.  As  we  go  upward  toward  the  vesico-uterine  fold  of  the  peritoneum,  the  separation  of  the 
bladder  becomes  much  easier.  The  separation  is  continued  laterally  beyond  the  borders  of  the 
cervix  and  uterus,  and  the  first  part  of  the  bladder  separa  tion  is  completed.  The  finger  introduced 
between  the  bladder  and  the  cervix  and  uterus  readily  makes  out  the  vesico-uterine  fold  of  the  perit- 


ANTERIOR    VA(;iNy\l,   CI^MO'lOiMY 


79 


Fig.   20. 


oneum,  and  a  narrow  straight  speculum  if  introduced  through  this  transverse  incision,  lifts  the 
bladder  upward,  and  discloses  this  peritoneal  fold  to  the  eye  if  desired  (Fig.  16).  The  finger 
introduced  along  the  anterior  wall  of  the  cervix  and  passed  to  its  lateral  borders  readily  feels  the 
two  pulsating  uterine  arteries. 


ANTEKIOR   VAGINAL   CELIOTOMY 


8l 


^,  Bos-se. 


YiG.  2T. — In  some  cases  where  the  anterior  vaginal  wall  is  very  lax,  as  in  cystocele,  a  short 
anterior  speculum,  if  introduced  under  the  urethra,  produces  the  taut  condition  desired  for  the 
next  manipulation.  The  two  artery  forceps  which  hold  the  upper  margin  of  the  transverse  inci- 
sion are  now  used  to  pull  down  the  anterior  vaginal  wall  and  put  it  on  the  stretch.  .\  pair  of  long, 
narrow  sharp-pointed  scissors  is  now  used  for  making  a  slight  snip  one-quarter  of  an  inch  long, 
immediately  between  the  two  artery  forceps.  This  discloses  the  thickness  of  the  vaginal  wall.  The 
lower  blade  of  the  sharp-pointed  scissors  is  now  gently  introduced  between  the  vaginal  wall  and 
the  bladder,  and  by  pressing  upward  with  this  lower  blade  the  latter  is  seen  to  lie  immediately 
beneath  the  vaginal  mucosa.     The  scissors  are  then  closed  and  the  cut  is  made. 

6 


ANTERIOR   VAGINAL   CKLIOTOMX 


^3 


Fig.  22. — After  each  snip,  the  lower  blade  of  the  scissors  is  progressi\ely  introduced  between 
the  vaginal  mucosa  and  the  bladder,  and  the  cuts  are  made  in  a  straight  line  upward  until,  if 
desired,  the  cut  reaches  within  an  inch  or  half  an  inch  of  the  external  opening  of  the  urethra. 


ANTERIOR    VA(;iNAL   CELIOTOMY 


85 


Fig.  23. — The  artery  forceps  on  the  left  side  of  the  operator  are  then  grasped  between  the 
thumb  and  first  two  fingers  of  the  left  hand,  and  that  side  of  the  anterior  vaginal  wall  and  its 
attached  area  of  the  bladder  is  everted  and  held  in  position  noted  above.  A  short  pair  of  curved 
blunt-pointed  scissors  now  makes  a  few  snips  in  the  immediate  vicinity  of  the  artery  forceps, 
which  step  begins  the  separation  of  the  bladder  and  its  connective-tissue  covering  from  the  vaginal 
mucosa. 


ANTERIOR   VAGINAL   CELIOTOMY 


Fig.  24.— ^^  ith  the  position  continued  as  in  figure  27,,  the  right  index  finger  covered  with 
gauze  pushes  and  rubs  the  bladder  and  its  connective-tissue  covering  away  from  the  anterior 
vaginal  wall,  a  manipulation  which  is  very  easy  in  women  who  have  borne  children.  Th.s  manip- 
ulation'is  more  difficult  in  nullipara;,  because  the  anterior  vaginal  wall  is  thinner  and  the  attach- 
ment of  the  bladder  is  more  firm.  The  thumb  covered  with  gauze  may  be  used  for  this  manipula- 
tion. In  practically  all  cases  the  bladder  peels  off  readily  from  this  anterior  vaginal  wall  and  the 
process  is  continued  upward  for  about  two  inches. 


ANTERIOR    VAOINAL    {l-llJOrOAI V  89 

This  separation  of  the  Ijladder  from  the  anterior  vaginal  \va]l 
is  a  point  of  great  importanee.  Not  only  does  the  longitudinal  incision 
give  us  more  room,  more  ready  approach  to  the  vesicouterine  fold 
of  peritoneum ;  not  only  does  it  give  us  more  room  after  the  peritoneum 
is  entered,  but  it  has  separated  the  bladder  from  its  connection  to 
the  anterodateral  vaginal  wall  and  from  its  union  to  the  lateral  borders 
of  the  uterus  and  the  adjoining  area  of  the  broad  ligament.  This 
complete  separation  of  the  bladder  from  its  utero-vaginal  relation 
puts  the  whole  organ,  so  to  speak,  within  our  hands.  The  bladder 
shrinks  to  one-third  of  its  usual  size,  and  even  if  nothing  more  were 
done  it  would  of  itself  be  a  better  operation  for  cystocele  than  the 
ordinary  form  of  anterior  colporrhaphy.  The  separation  of  the 
bladder  from  the  external  limits  of  the  anterior  vaginal  flaps  really 
frees  the  bladder  and  the  ureters  to  such  an  extent  that  when  the 
bladder  is  lifted  up  by  an  anterior  speculum  the  lower  param.etrium 
and  the  uterine  arteries  can  be  ligated  without  risk  to  the  ureters,  pro- 
vided the  sutures  are  passed  fairly  close  to  the  lateral  uterine  wall.  This 
inverted  T  incision  is  used  by  me  in  every  vaginal  operation  included 
under  the  title  of  celiotomy.  It  is  the  ideal  form  of  incision  if  one 
is  to  do  only  a  simple  colporrhaphy  for  cystocele,  for,  as  stated  above, 
the  bladder  is  entirely  removed  from  its  utero-vaginal  connection, 
it  retracts  up  behind  the  symphysis,  and  if  then  an  oval  piece  is  resected 
from  each  flap  and  then  the  edges  are  united  by  interrupted  sutures 
or  continued  sutures,  the  result  of  such  a  colporrhaphy  is  far  better 
than  that  obtained  by  the  usual  method  of  resecting  an  oval  anterior 
vaginal  area  and  leaving  the  bladder  still  attached  to  cervix,  uterus, 
and  vagina.  By  this  method  (Fig.  27)  we  may  readily  incise  and 
enter  the  bladder  for  the  removal  of  foreign  bodies  and  stones. 
This  method  is  the  ideal  one  for  the  surgical  treatment  of  vesical 
fistulas,  as  separation  of  the  bladder  from  its  environment  renders 
closure  of  the  vesical  opening  a  simple  step. 


90  VAGINAL   CELIOTOMY 

ENTERING  THE  PERITONEUM. 

Where  formerly  the  vesico-uterine  fold  was  pulled  down  with 
forceps  by  the  aid  of  the  guiding  fingers  (Fig.  i6)  the  lengthened 
vertical  incision  now  makes  this  procedure  readily  possible  with  the  aid 
of  the  eye.  I  have  long  since  discontinued  any  attack  on  the  plica  not 
made  with  the  aid  of  sight.  Here  lies  the  great  superiority  of  the 
inverted  1  -shaped  incision  with  complete  separation  of  the  bladder, 
for  we  then  have  a  ready  approach  to  the  peritoneum  after  the  bladder 
is  safely  lifted  up  by  the  anterior  speculum.  A  not  too  wide  speculum 
of  medium  length  is  introduced  beneath  the  bladder  and  the  bladder  is 
lifted  up  (Fig.  28).  This  exposes  the  point  at  which  the  peritoneum 
of  the  anterior  and  posterior  walls  of  the  vesico-uterine  cul  de  sac 
unite.     If  the  speculum  is  too  long  it  draws  the  peritoneal  fold  too  taut. 

At  this  point  the  peritoneum  is  grasped  in  the  median  line  with 
two  forceps  and  is  incised  with  a  blunt-pointed  scissors  between 
them.  This  incision  opens  the  peritoneal  cavity.  This  incision  is 
extended  upward  as  far  as  the  bladder  peritoneum  has  been  loosened, 
artery  forceps  being  put  on  at  successive  stages  to  bring  the  peritoneum 
clearly  into  the  field  (Fig.  29).  At  this  point,  if  desired,  the  bladder 
may  be  still  further  separated  and  the  longitudinal  incision  further 
increased.  The  base  of  the  vesico-uterine  pouch  may  be  likewise 
incised  transversely,  a  procedure  which  is  often  of  assistance  (Fig.  30). 

If  we  are  to  simply  enter  the  peritoneal  cavity  for  the  performance 
of  a  pelvic  operation,  and  are  not  to  sew  the  uterus  to  the  peritoneum 

Fig.  25. — The  same  manipulation  is  now  carried  out  on  the  other  flap,  the  artery  forceps 
being  held  with  the  left  hand  and  fingers,  as  illustrated  above,  or  else  they  may  be  held  with  the 
right  hand  and  the  snipping  with  the  scissors  may  be  begun  with  the  left  hand.  After  this  snipping 
has  been  done,  it  is  better  to  hold  the  artery  forceps  in  the  right  hand  and  to  peel  off  the  bladder 
with  the  left  thumb  covered  with  gauze.  In  peeling  off  the  bladder  as  in  figure  24,  the  process 
should  be  continued  down  to  the  lateral  margin  of  the  cervix  and  uterus.  As  the  bladder  is 
separated  along  the  two  lateral  sulci  oozing  and  bleeding  are  noted,  and  occasionally  a  small,  tiny 
artery  spurts,  for  we  are  approaching  the  ureter  and  the  uterine  arteries  and  their  accessory  arteries 
and  veins.  Occasionally,  it  is  necessary  in  the  manipulation  noted  in  figures  20  and  24,  to  use 
a  small  artery  f creep  s  and  place  a  ligature  on  a  spurting  vessel  located  over  the  bladder  or  on  the 
anterior  or  lateral  wall  of  the  cervix.     Usually  compression  alone  by  an  artery  forceps  suffices. 


ANTERIOR  VAGINAL   CELIOTOMY 


91 


v 


-^ 


w 


Fig.  25. 


ANTERIOR    \A(;i\AL   CELIOTOMY 


93 


Fig.  26. — Another  pair  of  arter}'  forceps  is  then  applied  to  either  edge  of  the  vaginal  flap 
a  little  below  the  highest  point  from  which  the  bladder  has  already  been  separated.  The  separa- 
tion or  peeling  off  of  the  bladder  i5  now  continued,  first  on  one  side  and  then  on  the  other,  with  the 
index  finger  or  thumb  of  either  hand  C9vered  with  gauze,  until  the  bladder  is  separated  as  far  as  the 
longitudinal  incision  has  extended.  As  we  approach  the  upper  area  depicted  in  tigure  26,  the 
vaginal  mucosa  in  the  region  of  the  urethra  is  often  extremely  thick  and  wrinkled  and  hyper- 
plastic. Here  the  bladder  may  be  separated  first,  and  then  the  longitudinal  incision  in  the  vaginal 
wall  mav  be  made  with  the  scissors. 


ANTIIRIOR    VACIXAl,    ClvlJO  TOM  V 


95 


Fig.  27. — On  completion  of  these  manipulations,  we  have  the  bladder  completely  separated 
from  the  anterior  wall  of  the  cervix  and  uterus  and  entirely  loosened  from  its  connection  to  the 
anterior  wall  of  the  vagina.  The  anterior  wall  of  the  vagina  is  now  represented  by  two  large 
lateral  flaps.  The  surface  of  the  bladder  usually  oozes,  but  spurting  vessels  need  be  compressed 
or  tied.  The  elasticity  of  the  bladder  wall  is  apparent  from  the  fact  that  it  shrinks  considerably 
in  size  and  has  a  tendency  to  be  drawn  up  toward  the  urethra  and  behind  the  symphysis.  An 
anterior  speculum  may  now  be  introduced  underneath  the  bladder,  and  the  bladder  is  lifted  up 
out  of  the  field  of  observation. 


ANTI'RIOR    \A(;i.\AJ.    CELIOTOMY 


97 


Fig.  28. — The  bladder  having  been  lifted  up  by  an  anterior  speculum  the  vesico-uterine  fold 
of  peritoneum,  which  now  comes  into  view,  may  be  grasped  and  pulled  downward  by  two  arterv 
forceps. 


ANTKRIOR    VACCINAL   CELIOTOMY 


99 


Fig.  29. — Between  the  two  artery  forceps  a  pair  of  long,  blunt  scissors  cut  through  this  perti  - 
oneal  fold.  The  lateral  borders  of  this  incision  are  grasped  by  artery  forceps  and  more  of  the 
peritoneal  fold  is  pulled  into  view,  and  the  incision  is  extended  still  further.  This  fold  of  the  perit- 
oneum which  is  being  pulled  into  view  by  successively  applied  artery  forceps,  is  loosely  attached 
to  the  posterior  wall  of  the  bladder,  and  its  separation  may  be  aided  by  the  introduction  of  the 
index  finger,  which  readily  peels  it  off.  In  this  manner,  a  longitudinal  incision  three  to  four  inches 
in  length  may  be  made  through  the  vesico-uterine  fold  of  the  peritoneum. 


ANTKRIOR    \A(;i.\Al.   ('i;i.I(rj(j.M V 


lOI 


Fig.  30. — In  addition  to  the  longitudinal  incision  through  the  peritoneum,  a  transverse  inci- 
sion may  be  extended  to  the  lateral  borders  of  the  uterus.  In  many  cases  no  longitudinal  incision 
is  made  and  the  peritoneum  is  incised  transversely,  in  the  manner  depicted  above,  by  the  scissors. 


an'I'i;ri()R  vaginal  ci'.i.io'iomy  103 

(vcsico-suspcnsion,  vugino-suspcnsion),  (jr  if  wc  arc  to  do  a  vaginal 
hysterectomy  the  transverse  incision  suffices.  'J'his  may  be  readily 
closed  on  completion  of  operation  Ijy  two  or  three  interru])ted  sutures. 
If,  however,  we  wish  to  attach  the  uterus  to  the  jK'ritoneum  which 
has  been  dissected  from  the  posterior  wall  of  the  bladder  (vesico- 
suspension),  or  if  we  are  to  attach  any  area  of  the  uterus  to  any  point 
of  the  anterior  vaginal  flaps  with  the  peritoneum  intervening  between 
these  two  (vagino-suspension)  the  vesico-uterine  plica  should  be 
incised  in  a  longitudinal  fashion. 

It  is  of  advantage  to  pass  a  suture  or  to  apply  artery  forceps  at 
the  upper  end  of  the  plica  incision,  if  longitudinal,  and  two  sutures 
at  the  lateral  borders  of  the  incision.  By  this  means  the  peritoneum 
may  be  readily  brought  into  view,  on  completion  of  the  operation, 
for  the  purpose  of  sewing  the  incision  in  the  peritoneal  fold. 

DELIVERY  OF  THE  UTERUS  AND  ADNEXA. 

With  the  anterior  vaginal  incision  it  is  always  advisable  to  deliver 
the  uterus  into  the  vagina  before  attempting  to  deliver  the  adnexa 
or  to  carry  out  an  intraperitoneal  examination  or  any  operative  pro- 
cedure. This  is  easy  if  there  are  no  adhesions,  if  the  ligamentum 
infundibulo-pelvicum  is  long,  and  if  the  upper  part  of  the  broad  liga- 
ment is  not  sclerosed.  If  these  abnormal  conditions  are  not  present, 
it  is  easy  to  subsequently  deliver  nonadherent  tubes  and  ovaries. 
If  any  of  the  above-mentioned  conditions  prevail,  the  delivery  of 
the  uterus  and  especially  of  the  tubes  and  ovaries  is  more  difficult. 
A  wide  speculum  of  fair  length  is  introduced  through  any  form  of 
incision  which  has  been  made  in  the  vesico-uterine  peritoneum,  and 
frequently  intestine  or  omentum  will  then  present  in  the  field.  At 
this  stage,  the  short  posterior  retractor  is  removed,  and  a  long  posterior 
retractor  is  introduced,  which  is  used  to  push  the  cervix  back  and 
thus  aid  in  bringing  the  fundus  forward  (the  volsella  being  taken  off), 
or  else  bv  the  aid  of  the  volsella,  if  not  removed  from  the  cervix,  the 


I04  VAGINAL   CELIOTOMY 

cervix  is  pushed  and  held  back  firmly,  which  manipulation  has  also 
a  tendency  to  rotate  the  fundus  forward.  With  great  care  a  pair  of 
volsella  takes  a  firm  grasp  on  the  anterior  uterine  wall  at  the  highest 
accessible  point,  which  precedure  is  perhaps  best  done  before  the 
cervix  is  pushed  back  (Fig.  31).  Gentle  traction  on  this  volsellum 
serves  to  pull  the  lower  part  of  the  uterus  more  clearly  into  view. 
Volsella  are  applied  regularly  at  higher  points  to  the  anterior  wall 
of  the  uterus  (Fig.  32),  and  by  gentle  traction,  by  movement  from 
side  to  side,  aided  by  a  slight  rotary  movement,  the  fundus  is  gradually 
pulled  into  view  and  then  pulled  out  into  the  vagina  along  the  under 
surface  of  the  wide  speculum  which  was  introduced  anteriorly  into 
the  peritoneal  cavity  (Fig.  t,t,).  At  this  point  it  becom^es  evident 
that  a  long  longitudinal  incision  in  the  anterior  vaginal  wall  and  a 
thorough  separation  of  the  bladder,  especially  at  its  lateral  attachments 
to  the  cervix,  long  incisions  into  the  vesico-uterine  peritoneum,  and 
the  introduction  into  the  peritoneal  cavity  of  a  wide  speculum,  are 
important  factors  in  bringing  readily  into  the  vagina  a  uterus  of  even 
large  size. 

When  the  uterus  is  fixed  through  adhesions  to  its  posterior 
wall  it  may  be  advisable,  instead  of  using  volsella,  to  pass  sutures 
through  the  anterior  wall  of  the  uterus  at  successively  higher  points 
and  in  this  way  bring  the  fundus  toward  the  vagina.  Sutures  when 
tearing  out  would  lacerate  the  uterus  less  than  the  volsella  and  they 
permit  of  more  ready  tactile  approach  to  the  fundus  and  posterior 
wall  of  the  uterus  in  separating  adhesions  with  the  fingers  or  with 
the  scissors  from  the  posterior  wall.  Volsella  fill  up  the  vagina. 
When  they  do  tear  out  they  cause  greater  injury. 

Sometimes  it  is  necessary  to  pull  one  side  of  the  uterus  so  that 
one  horn  lies  nearer  the  median  fine.  Sometimes  it  is  necessary  to 
pass  side  retractors  into  the  peritoneal  cavity  to  deliver  a  large 
fundus.  When  the  uterus  has  been  drawn  into  the  vagina  the  space 
left  between  its  posterior  wall  and  the  anterior  speculum  is  a  very 


ANTEKIOR    VA(;i.\AI.    CKLIOTO.MV 


JO: 


Fig.  31. — After  the  vesico  uterine  fold  of  peritoneum  has  been  incised,  either  by  a  wide  trans- 
verse cut  or  by  a  long  longitudinal  incision,  a  fairly  wide,  long  speculum  is  introduced  into  the 
peritoneal  cavity,  and  is  pressed  up  firmly  against  the  symphysis.  A  pair  of  volsellum  forceps 
now  grasps  the  anterior  wall  of  the  uterus  within  the  peritoneal  cavity,  care  being  taken  not  to 
grasp  the  omentum  or  intestine,  which  often  now  present  in  the  field  of  operation.  By  a  pull  on 
these  volsellum  forceps  the  fundus  of  the  uterus  is  drawn  for^vard  and  another  pair  is  applied 
above  the  first  pair,  and  so  on  in  succession  until  the  fundus  is  reached.  As  this  manipulation 
is  being  carried  out,  the  operator  or  an  assistant  is  to  push  the  cer\-i.x  backward  into  the  vagina. 


ANTI'RIOR   VAGINAL   CELIOTOMY 


107 


Fig.  32. — As  the  fundus  begins  to  appear,  the  last  apphed  volsellum  is  pulled  forward  and  the 
uterus  is  drawn  forward  from  side  to  side,  so  that  by  a  series  of  rotary  movements  it  is  gradually 
pulled  through  the  peritoneal  incision.  At  the  same  time  it  is  of  greatest  importance  to  push  the 
cervix  back  until  it  has  eventually  been  moved  up  to  the  upper  part  of  the  vagina.  If  necessar}-, 
another  pair  of  volsellum  forceps  is  appUed,  care  being  taken  that  their  application  is  made  to  the 
middle  line  of  the  uterus.  In  the  act  of  pulling  the  fundus  through  the  peritoneal  incision  into  the 
vagina,  it  is  sometimes  difficult  to  tell  whether  we  are  applpng  volsella  to  the  median  part  of  the 
uterus  or  whether  the  forceps  have  been  applied  to  one  or  other  of  the  cornua,  in  which  event 
the  uterus  may  or  may  not  be  so  readily  pulled  forward,  and  some  of  the  larger  veins  in  the  broad 
ligament  may  be  punctured  and  cause  oozing. 


ANTl'lRIOR    VAC;iXAL    Vl'AAOTOMY 


109 


Fig.  S3- — Shows  the  uterus  drawn  out  through  the  vagina  and  beyond  the  vulva  in  cases  with 
no  adhesions  of  the  adnexa  and  with  nonsclerosed  broad  ligaments.  The  tubes  and  ovaries  are 
readily  brought  forward  into  view  over  the  posterior  wall  of  the  uterus.  It  is  now,  especially  that 
intestine  and  omentum  may  present.  They  may  be  kept  out  of  the  field  of  operation  by  gauze 
sponges  on  sponge  holders,  or  by  elevating  the  foot  of  the  table. 


ANTERIOR   VAGINAL   CELIOTOMY  III 

roomy  one,  provided  the  longitudinal  incision  in  the  anterior  vaginal 
wall  has  been  a  long  one,  provided  the  incision  into  the  vesico-uterine 
fold  has  been  a  long  one,  and  provided  the  speculum  is  wide.  The 
fingers  may  then  be  introduced  through  this  space,  may  palpate  the 
tubes  and  ovaries,  bring  tliem  into  view,  loosen  adhesions,  draw  out 
small  cysts  or  tumors,  or  enucleate  adherent  tumors  or  pus  sacs.  De- 
livery of  the  uterus  is  more  difficult  if  the  incision  into  the  peritoneum 
has  been  a  longitudinal  one  than  if  the  incision  has  been  a  transverse 
one.  While  the  uterus  is  being  delivered  into  the  vagina  through  a 
longitudinal  incision  in  the  peritoneal  plica,  the  lateral  margins  of 
this  peritoneal  plica  are  put  on  the  stretch  and  more  so,  since  the  wide 
anterior  vaginal  speculum  has  been  introduced  to  lift  the  bladder  up 
out  of  the  way.  The  ovaries  and  tubes  must  then  be  delivered  manu- 
ally or  otherwise  around  these  firm  peritoneal  pillars,  a  manipulation 
which  is  frequently  found  to  be  anything  but  simple, 

INDICATIONS  FOR  ANTERIOR  COLPOCELIOTOMY. 

Anterior  vaginal  celiotomy  is  either  primary,  and  done  as  a  celiotomy 
for  the  purpose  of  performing  an  intraperitoneal  manipulation  or 
operation,  or  else  it  is  simply  an  essential  step  in  the  performance  of  an 
operation  for  cystocele,  for  prolapse,  etc.  We  are  concerned  in  the 
selection  of  this  route  not  so  much  with  what  can  be  accomplished 
through  the  vagina,  but  with  what  in  our  hands  may  be  done  well, 
safely,  and  with  advantage  to  the  patient  and  with  benefits  superior 
to  those  offered  by  abdominal  laparotomy. 

There  are  certain  disorders  of  a  gynecological  nature  for  the  correc- 
tion of  which  vaginal  operation  should  be  selected  because  it  oft'ers 
the  only  cure  or  a  better  and  more  certain  cure  of  the  condition  in  ques- 
tion, or  because  such  an  operation  is  less  dangerous  or  more  readily 
accepted  by  the  patient. 

This  is  especially  the  case  in  the  surgical  treatment  of: 

I.  Cystocele. 


112  VAGINAL    CELIOTOMY 

2.  Descent  of  the  uterus. 

3.  Prolapse  of  the  uterus. 

4.  Many  cases  involving  hysterectomy. 

The  indications  which  I  have  made  for  myself  are  the  result  of 
observation  and  study,  modified  by  the  test  of  actual  experience  over  a 
period  of  many  years.  They  are  not  given  with  any  other  purpose  than 
to  express  a  personal  conviction  with  the  feeling  that  the  reason  for 
every  choice  is  founded  on  the  result  of  practical  tests.  One  point  is 
to  be  made  clear  and  that  is,  that  vaginal  celiotomy  is  not  so  difficult 
in  multiparae  with  roomy  vagina,  when  the  cervix  can  be  pulled  far 
down  toward  the  perineum,  and  it  is  in  these  cases  that  most  of  the 
following  indications  are  found. 

Indications  which  I  feel  worthy  of  general  acceptance  for  the  use  of 
vaginal  celiotomy  are : 

1.  Exploratory  celiotomy  for  non-tangible  pelvic  conditions,  such 
as  sterility  or  suspected  ectopic  gestation,  accomplished  by  delivery  of 
uterus  and  adnexa. 

2.  For  the  production  of  artificial  sterility  by  excision  of  part  of  the 
tubes. 

3.  Conservative  or  minor  operations  on  adnexa  with  only  slight 
or  cobweb  adhesions,  especially  if  at  the  same  time  retroflexion  or 
retroversion  or  descent  or  cystocele  furnish  indication  for  the  per- 
formance of  vaginal  suspension. 

4.  For  the  removal  of  small  movable  cystic  tumors  of  the  ovary  or 
tube. 

5.  For  the  removal  of  small  fibroids  of  the  uterus,  care  being  taken 
to  select  such  cases  as  are  suitable  for  myomectomy. 

6.  Vaginal  celiotomy  may  be  used  for  movable  retroflexion  or 
retroversion  of  the  uterus,  to  be  corrected  either  by  vaginal  suspension 
of  the  uterus,  vaginal  fixation  of  the  uterus,  vaginal  shortening  of  the 
round  ligaments,  or  fixation  of  the  round  ligaments  to  the  anterior  wall 
of  the  uterus. 


ANTERIOR    VAGINAL    CELIOTOMY  1  I  3 

The  Alexander-Adams  operation  meets  all  the  indications  unless 
we  are  deahng  with  pathological  ovaries,  tubal  disease,  peritoneal 
adhesions  or  other  pathological  intraperitoneal  involvements  evidenced 
by  symptoms.  With  disease  of  the  appendix,  or  if  we  are  dealing  with 
congenital  retroflexion  associated  with  long  uterus  or  short  anterior 
vaginal  wall,  a  vaginal  operation  is  not  advisable. 

If  the  retroflexion,  retroversion  or  retrodisplacement  is  associated 
with  parametritis  involving  the  posterior  parametrium  or  the  utero- 
sacral  ligaments,  no  matter  what  operation  is  chosen,  the  posterior 
parametrium  should  be  incised  and  freed  by  a  transverse  incision 
passing  into  the  cul  de  sac  of  Douglas,  and  this  incision  should 
then  be  sewed  in  a  longitudinal  direction  (Fig.  12). 

7.  For  the  correction  of  cystocele,  with  or  without  uterine  dis- 
placement, to  be  treated  by  the  method  of  vaginal  suspension  in  the 
child-bearing  years  or  by  vaginal  fixation  in  the  non-bearing. 

8.  For  descent  of  the  uterus,  if  we  are  dealing  with  a  large,  heavy 
organ,  especially  if  the  patient  be  fat,  if  the  abdominal  walls  are  lax; 
to  be  corrected  by  vaginal  suspension  in  the  child-bearing  age;  by 
vaginal  fixation  in  the  non-bearing  patient,  plus  amputation  of  the 
cervix  and  perineorrhaphy  if  needed. 

9.  For  the  cure  of  prolapse  of  a  large  heavy  uterus.  A  high  amputa- 
tion of  the  cervix,  resection  of  the  posterior  vaginal  wall,  and  a  high 
perineorrhaphy  are  essential  additions  to  a  thorough  vaginal  fixation. 
This,  of  course,  is  to  be  done  only  in  the  non-bearing  woman,  and 
in  the  others  an  area  of  the  tubes  is  to  be  excised. 

10.  (a)  Hysterectomy  for  uterine  disease  (including  carcinoma 
of  the  fundus  and  fibromyomata),  if  the  uterus  is  not  too  large  to  be 
delivered  into  the  vagina  and  if  it  is  not  essential,  as  in  carcinoma  of 
the  portio  or  cervix,  to  remove  an  unusually  wide  area  of  the  base 
of  the  broad  ligaments,  etc.  {b)  The  most  frequent  indication  for 
hysterectomy  is  found  to  be  fibrosis  uteri. 

The  choice  of  the  vaginal  operation  is  debatable. 


114  VAGINAL   CELIOTOMY 

1.  In  certain  cases  of  ectopic  gestation.  This  operation,  in  my 
opinion,  is  permissible  if  we  are  not  dealing  with  tubal  abortion  or 
tubal  rupture;  if  there  is  no  actual  active  hemorrhage  going  on,  and 
if  there  is  no  hematocele.  This  really  includes  cases  where  vaginal 
celiotomy  is  done  for  diagnostic  reasons  in  suspected  ectopic  gesta- 
tion, and  then  conditions  being  found  favorable  the  operation  is 
completed  vaginally.  As  to  the  advisability  of  this  operation  in  cases 
which  are  so  often  diagnosed  only  after  the  symptoms  of  intraperit- 
oneal hemorrhage  make  themselves  evident,  I  am  opposed  to  the 
vaginal  route,  for  haste  is  a  most  essential  element,  and  for  that 
reason  an  abdominal  operation  is  indicated  in  almost  all  cases. 
Diihrssen,  however,  employs  vaginal  celiotomy  for  70  per  cent,  of  his 
cases  of  ectopic  gestation. 

2.  Not  too  large  movable  unilocular  cystic  tumors,  situated  an- 
teriorly to  uterus.  The  mortality  in  abdominal  treatment  of  movable 
cystic  tumors  of  whatever  size  is  so  slight  that  the  argument  of  lower 
mortality  can  scarcely  be  made.  In  the  case  of  multilocular  tumors, 
however,  time  is  taken  up  with  the  successive  vaginal  opening  of  the 
various  chambers. 

3.  Inflammation  of  adnexa  in  multipara  with  roomy  vagina,, 
only  if  the  adnexal  tumors  are  not  situated  too  far  lateral  to  the  uterus. 
Salpingo-oophorectomy  or  hysterectomy.  I  do  not  consider  the 
vaginal  method  advisable  for  the  removal  of  pus  tubes  or  of  tubo- 
ovarian  cysts  adherent  to  the  lateral  pelvic  walls,  unless  at  the  same 
time  a  hysterectomy  is  done,  for  without  the  latter  step  the  operation 
is  not  so  clean-cut;  finger  dissection  is  rendered  more  difficult;  raw 
surfaces  are  left;  the  peritoneum  is  more  extensively  injured;  the 
sigmoid  likewise.  It  is  difficult  to  check  oozing,  and  drainage,  if 
needed,  means  incision  of  the  posterior  cul  de  sac. 

If  the  uterus  is  not  drawn  into  the  vagina  we  have  to  begin  the 
removal  of  the  tubes  at  the  uterine  horn  and,  by  tugging  on  hgatures, 
work  gradually  along  with  the  fingers  which  from  time  to  time  are 
introduced  into  the  pelvic  cavity  to  loosen  adhesions. 


ANTERIOR    VAGINAL    CELIOTOMY  J  I  5 

If  the  uterus  can  be  drawn  into  the  vagina  we  have  a  space  over 
the  posterior  wall  of  the  uterus  sufficient  to  introduce  two  fingers 
of  one  hand,  and  then  the  lingers  of  the  other,  to  loosen  the  adhesions. 

If  the  uterus  is  fixed  by  adhesions  to  its  posterior  wall  it  may 
be  necessary  to  do  a  posterior  celiotomy,  in  order  to  free  the  fundus. 

If,  as  usual,  both  tuljcs  are  badly  involved,  this  entails  a  great  deal 
of  work;  copious  oozing,  much  denudation  of  peritoneum,  and  what 
remains  is  an  absolutely  worthless  uterus.  Hence  all  such  conditions 
should  be  treated  by  vaginal  hysterectomy  with  splitting  of  the  uterus. 

Otherwise,  great  difficulty  is  experienced  in  reaching  the  ligamen- 
turn  infundibulo-pelvicum  and  the  brittleness  of  this  ligament  often 
causes  decided  bleeding. 

If  we  attempt  conservatism  in  operating  on  pus  tumors  and  leave 
the  uterus  and  one  ovary  behind,  we  often  have  to  drain  through 
the  cul  de  sac  of  Douglas.     Hence  abdominal  laparotomy  is  best. 

Vaginal  hysterectomy  for  double  pyosalpinx,  when  we  have  reason 
for  removing  the  chronically  inflamed  uterus  at  the  same  time,  is  a 
valuable  operation.  In  the  vast  majority  of  cases  of  pyosalpinx,  the  ab- 
dominal operation  permits  of  perfect  removal  of  both  involved  tubes, 
the  thorough  stopping  of  all  oozing,  and  the  careful  covering  of  areas 
denuded  of  peritoneum.  Thorough  resection  of  the  tubes  at  the  uterine 
cornua  permits  of  retention  of  the  uterus  without  risk  of  future  infec- 
tion from  that  organ.  After  double  abdominal  salpingo-oophorectomy, 
ventral  fixation  or  the  Gilliam  operation  is  always  practised  by  me 
in  order  that  the  uterus  may  be  kept  well  away  from  future  possible 
adhesions. 

4.  Fairly  large  and  irregular  fibroids,  where  preliminary  delivery 
of  the  uterus  is  not  possible,  for  myomectomy. 

5.  Fairly  large  fibroids,  not  intraligamentous,  for  hysterectomy. 
Vaginal   celiotomy  is  contraindicated   in   the   following  instances. 

These    naturally   include   all   the   conditions   not   mentioned   above, 
but  inasmuch  as  the  element  of  situation,  size,  adhesions,  and  danger 


Il6  VAGINAL   CELIOTOMY 

of  injury  to  the  bladder,  uterus,  and  intestine,  furnish  the  basis  for 
the  contraindications  an  enumeration  of  the  various  contraindications 
shows  the  logic  for  this  grouping. 

(i)  a.  In  the  presence  of  a  pregnant  uterus,  b.  Shortly  after 
labor  or  abortion,  except  in  the  possible  event  of  hysterectomy. 

(2)  If  a  previous  vaginal  celiotomy  or  separation  of  the  bladder 
has  been  done. 

(3)  If  the  appendix  is  involved,  as  not  infrequently  happens  with 
right-sided  tubo-ovarian  conditions,  and  if  the  abdominal  method 
permits  of  an  advantageous  operation  (which  is  not  the  case  in  cystocele 
and  prolapse). 

(4)  If  the  gall-bladder  or  other  intra-abdominal  organs  are  to  be 
explored. 

(5)  a.  Nulliparae  or  multiparae  with  such  a  small  vagina  that  it  is 
necessary  to  incise  the  perineum,  b.  Nulliparae  in  whom  the  anterior 
fornix  is  of  such  small  curve  as  not  to  permit  of  a  long  incision  or  in 
whom  the  cervix  cannot  readily  be  brought  down  to  the  perineum. 

(6)  Tumors  fixed  antero-laterally  to  the  uterus,  which  situation 
makes  it  difficult  to  bring  the  uterus  into  the  vagina.  An  essential  to 
ready  removal  of  structures  by  vaginal  celiotomy  is  the  ability  to  bring 
the  uterus  into  the  vagina  so  that  then,  by  various  manipulations,  the 
tube,  ovary  or  tumor  may  be  enucleated  and  brought  into  view. 

(7)  In  instances  where  injury  to  the  uterus  in  inflammatory  diseases 
may  cause  extension  to  the  other  side.  I  think  the  vaginal  operation 
is  founded  on  a  poor  basis  in  the  case  of  one-sided  pyosalpinx  or  salpin- 
gitis; for  the  manipulation  through  which  the  uterus  goes  in  the  per- 
formance of  a  vaginal  celiotomy  is  such  that  its  structure  to  a  certain 
extent  is  invaded  and  the  probability  of  stirring  up  a  recrudescence  of 
the  original  active  or  latent  infection  and  thus  transmitting  it  to  the  non- 
affected  side  is  great.  Therefore,  an  abdominal  operation  is  better, 
unless  we  are  dealing  with  a  double  pyosalpinx  and  chronic  metritis,  in 
which  case  a  complete  hysterectomy,  preferably  vaginal,  is  indicated. 


CONSERVATIVI';    f)lM;RATI(J\S  II7 

(8)  Tu])es,  ovaries,  or  tumors  fixed  far  to  the  lateral  wall  of  the 
pel\is,  including  double  pyosalpinx,  unless  hysterectomy  is  done. 

((;)  A  uterus  fixed  by  dense  adhesions  to  the  posterior  pelvic  wall 
or  to  the  sigmoid  or  the  rectum. 

(10)  Tumors  fixed  posteriorly  to  the  uterus. 

(11)  Ovarian  tumors  with  twisted  pedicles. 

(12)  Large  multilocular  ovarian  tumors,  especially  if  adherent. 

(13)  Large  solid  ovarian  tumors. 

(14)  Dermoid  tumors  of  the  ovary,  especially  if  fixed. 

(15)  Intraligamentous  tumors  and  intraligamentous  hematomata 
if  high  up  in  the  broad  ligament. 

(16)  Most  cases  of  ectopic  gestation. 

(17)  Large  irregular  fibroids  of  the  uterus,  especially  those  with 
intraligamentous  extension.  Morcellement  is  a  dangerous  procedure  in 
the  case  of  degenerating  or  necrotic  tumors.  In  my  opinion  the  best 
method  for  the  treatment  of  large  fibroid  of  these  types  in  the  com- 
bination of  the  vaginal  and  abdominal  routes,  if  we  believe  in  the 
removal  of  the  cervix. 

CONSERVATIVE  OPERATIONS. 

The  method  of  entering  the  peritoneal  cavity  by  the  anterior  route 
is  no  longer  a  haphazard  procedure.  It  is  a  method  which  does  no 
injury  to  any  structure;  it  makes  clean-cut  wounds  and  nicely  dissected 
surfaces  and  gives  entrance  into  the  peritoneal  cavity  through  a  space 
several  inches  in  diameter. 

This  method  has  great  value  as  a  diagnostic  step.  The  vaginal 
method  has  this  advantage  over  the  Alexander-Adams,  for  it  permits 
of  the  examination  of  the  adnexa,  where  so  often  are  found  cobweb 
adhesions  of  the  tubes  and  ovaries,  hydrosalpinges,  small  dermoids 
and  small  cystic  degenerations  of  the  ovary,  which  latter  condition, 
according  to  Diihrssen,  may  cause  severe  menorrhagia  which  can  only 
be  overcome  by  resection  of  part  of  the  ovaries. 


Il8  VAGINAL   CELIOTOMY 

It  is  evident  that  the  long  longitudinal  incision  in  the  anterior 
vaginal  wall  and  a  thorough  separation  of  the  bladder,  especially  at 
its  lateral  attachments  to  the  cervix,  a  roomy  incision  into  the  vesico- 
uterine peritoneum,  the  introduction  into  the  peritoneal  cavity  of  a  wide 
speculum  are  important  factors  in  bringing  the  adnexa  readily  into  the 
vagina.  If  the  uterus  be  large,  or  if  the  uterus  swells  through  conges- 
tion after  its  delivery  in  the  vagina  (a  change  which  often  makes  re- 
position more  difficult),  the  space  above  the  uterus  can  be  made  more 
roomy  for  intraperitoneal  manipulations  if  the  posterior  speculum 
is  taken  out,  and  if  the  fundus  of  the  uterus  is  then  pulled  down  or 
pressed  down  against  the  perineum.  Rotation  of  the  uterus  so  that 
one  horn  lies  more  anteriorly  brings  the  adnexa  of  this  horn  more 
readily  into  view,  and  discloses  the  full  width  of  the  broad  hgament 
for  examination  or  operative  procedures.  The  loosening  of  mild 
cobweb  adhesions  with  a  freely  movable  uterus  is  accomplished  almost 
by  the  dehvery  of  the  uterus  itself.  After  the  uterus  is  in  the  vagina 
gauze  sponges  or  holders  or  the  introduced  fingers  readily  roll  the  ad- 
nexa into  view. 

If  the  contents  of  the  tube  are  serous,  the  outer  end  may  be  opened 
and  the  tube  may  be  washed  out  with  salt  solution.  If  the  outer 
end  is  too  firmly  closed,  this  area  may  be  resected  and  a  new  ostium 
may  be  made  with  union  of  the  mucosa  to  the  peritoneum  (Fig.  34), 
or  one  or  more  ostia  may  be  made  in  the  course  of  the  tube.  If  the 
tube  is  resected  to  any  great  extent,  it  may  be  split  in  a  longitudinal 
manner  at  the  remaining  outer  end,  and  then  by  union  of  mucosa 
to  the  peritoneum  a  large  special  ostium  is  established.  The  ovary 
may  be  readily  brought  into  view  if  the  ligamentum  ovarii  and  the 
ligamentum  infundibulo-pelvicum  are  not  too  shortened   (Fig.   35). 

Cysts  may  be  opened,  corpus  luteum  cysts  may  be  shelled  out 
and  hematoma  of  the  ovary  may  be  removed.  Any  desired  portion 
of  the  ovary  may  be  removed  (Fig.  36).  If  the  entire  ovary  is  to  be 
taken  out  the  meso-ovarium  should  be  ligated  by  mattress  sutures 


CONSER\ATI\^K    OPKRATIOXS 


119 


Fig.  34. — The  outer  end  of  the  tube  is  resected  in  an  oblique  manner  after  mattress  sutur:s 
have  been  applied  to  the  mesosalpinx  parallel  to  the  area  to  be  resected.  The  mucosa  is  then  united 
with  the  peritoneal  covering  of  the  tube  throughout  the  entire  circumference.  If  an  ostium  is 
made  in  the  course  of  the  tube  by  the  aid  of  a  long  slit  or  by  exsectioh  of  an  oval  piece,  then 
the  mucosa  and  peritoneum  are  united  in  the  same  manner. 


("ONSI'-RVyMIVK    OI'KRATIONS 


121 


Fig.  35. — The  ovary  may  be  brought  into  the  field  of  operation  by  clamps  applied  in  succes- 
sion to  the  upper  part  of  the  broad  ligament,  to  the  tube,  or  to  the  ligamentum  ovarii.  The 
ovarian  tissue  at  the  meso-ovarium  is  then  grasped  so  that  the  ovary  may  be  removed  by  mattress 
sutures  applied  to  the  meso-ovarium  or  else  any  desired  area  of  the  ovary  may  be  taken  away. 


C^ON  S 10  R  VA'J'  I  \  ■  !•;    ()  P  i;  R  A  'J- 1 0  N  S  12  3 

applied  Ijcforc  any  cuttinijj  is  done.  If  the  ovary,  however,  cannot 
be  drawn  (jut  sufficiently  well  the  mattress  sutures  should  be  tied 
with  cutting  after  each  suture  is  applied,  passing  thus  step  by  step 
to  the  extreme  limit  of  the  ovary. 

Conservative  o]3erations  on  the  adnexa,  especially  where  little 
is  felt  on  bimanual  examination,  as  in  cases  of  sterility,  furnish  no 
contraindication,  as  a  rule,  because  of  adhesions  or  pus  accumulations. 
However,  I  do  not  find  the  method  well  adapted  to  conservative  opera- 
tions in  nulliparae,  for  these  vaginal  intraperitoneal  operations  do  not 
permit  of  nice  adaptation,  of  clean-cut  edges,  of  cutting  or  lengthening 
the  ligamentum  infundibulo-pelvicum,  all  elements  greatly  to  be  desired 
in  every  case,  especially  in  those  where  slight  adhesions  have  produced 
marked  suffering. 

The  vaginal  route  can  safely  be  used  for  the  removal  of  small  mova- 
ble hard  ovarian  tumors,  small  fibroids  of  the  uterus,  and  smaller  or 
large  movable  ovarian  cysts.  It  may  also  be  used  in  certain  early 
cases  of  ectopic  gestation  where  no  active  bleeding  is  going  on. 

Unless  there  is  sclerosis  of  the  ligaments  the  ovary  comes  easily 
into  the  field  of  operation.  If  not,  the  hgamentum  ovarii  or  the  tube 
and  upper  part  of  the  ligament  are  grasped  by  forceps,  and  in  this 
manner  the  ovary  is  brought  where  operative  procedures  on  it  may 
be  carried  out  with  ease  (Fig.  35).  If  a  horn  of  the  uterus  is  rotated 
anteriorly,  the  corresponding  tube,  round  ligament  and  ligamentum 
ovarii  are  more  easily  approached.  If  retractors  are  introduced  in 
the  antero-lateral  region  of  the  operative  area  the  adnexa  are  more 
readily  exposed. 

Ovarian  cysts,  unless  very  small,  must  be  punctured  and  freed  of 
their  contents  before  they  can  be  delivered.  If  the  cyst  wall  is  thick 
delivery  is  simple,  for  various  areas  are  grasped  in  succession  until 
finally  the  cyst  lies  outside  of  the  vulva;  only  the  pedicle  remains  to 
be  ligated.  If  the  cyst  wall  is  thin  this  method  of  delivering  the  tumor 
is  not  easy  as  too  energetic  traction  tears  the  structures.     In  the  case 


124  VAGINAL   CELIOTOMY 

of  dermoid  cysts  the  same  procedure  is  necessary.  It  is,  therefore, 
always  advisable,  before  puncturing  cysts,  to  introduce  plenty  of  gauze 
into  the  peritoneal  cavity  to  catch  up  as  much  of  the  outflow  as  may 
not  pass  out  through  the  incision.  It  is  always  preferable  to  introduce 
a  trocar  into  the  larger  cysts,  and  in  this  way  keep  the  structures 
more  clean,  and  prevent  dribbling  into  the  peritoneal  cavity. 

Ectopic  gestation,  with  the  tube  not  greatly  enlarged,  may  be  treated 
conservatively  through  the  vagina.  With  small  ectopic  tumors  an 
operation  through  the  vagina  is  occasionally  to  be  preferred.  With 
this  method  it  is  easy  to  remove  an  ovum  not  yet  expelled  from  the 
tube.  The  uterus  is  brought  out  and  the  tubes  become  visible  and 
may  be  reached  by  the  fingers;  the  corresponding  ovary  with  the  tube 
is  loosened  from  adhesions  and  is  brought  out  into  the  field  of  operation. 
If  the  tube  is  intact,  it  is  split,  the  egg  is  removed  and  incision  is  closed, 
so  that  the  lumen  is  preserved.  If  the  tube  cannot  be  preserved,  it 
is  removed  by  tying  the  mesosalpinx  in  small  sections;  the  end  of 
the  tube  remaining  near  the  cornu  is  left  open  if  the  mucous  membrane 
looks  normal.  The  retained  end  of  the  tube  is  split  and  the  mucous 
membrane  around  the  incision  is  united  with  the  serosa  forming  a 
large  artificial  open  end  (Fig.  34). 

Vaginal  myomectomy  should  only  be  attempted  in  roomy  vagina. 
In  the  case  of  subperitoneal  tumors  it  should  be  our  endeavor  to 
deliver  the  uterus  into  the  vagina,  provided  the  uterus  is  not  too  large 
or  irregular  in  outline  (Fig.  37). 

Vaginal  myomectomy  is  indicated  with  tumors  the  size  of  a  fist, 
when  these  make  interference  necessary  through  decided  continued 
bleedings,  or  through  pressure  symptoms.  One  can  never  make  a 
mistake  if  he  limits  this  indication  to  soHtary  tumors.  If  many  nodules 
are  present,  it  is  not  alone  possible  that  one  or  more  of  these  may 
be  left  behind,  but  the  uterus  may  be  so  cut  up  and  mutilated,  that 
restoration  of  a  passably  functionating  organ  may  be  impossible. 
With  the  presence  of  numerous  nodules,  especially  of  the  subperitoneal 


CONSERVA'I'IXl';    OFICRATIOXS 


125 


Fig.  36. — A  single  large  follicle  cyst  or  a  corpus  luteum  cyst,  or  a  hematoma  of  the  ovary 
may  be  shelled  out,  or  any  desired  part  of  the  ovary  may  be  exsected  in  wedge-shaped  manner  and 
the  remaining  structure  of  the  ovary  may  then  be  brought  together  by  mattress  sutures  which 
should  not  be  tied  too  tightly.     If  the  meso-ovarium  is  ligated  in  its  entirety  the  ovary  atrophies. 


CONSERVATIVE    OPJCRATIOXS 


127 


Fig.  37 . — The  removal  of  subperitoneal  fibroids  is  accomplished  by  incision  of  the  peritoneum 
over  the  summit  of  the  tumor.  The  tumor  is  then  grasped  by  volsellum  forceps  and  the  handle 
of  the  knife  or  blunt-pointed  scissors  are  then  used  to  shell  out  the  tumor  from  its  covering  of  per- 
itoneum and  from  its  uterine  bed.  The  resulting  opening  must  be  closed  so  that  no  spaces  are 
left.  In  the  case  of  small  tumors  this  may  be  done  by  interrupted  peritoneal  sutures  passed 
deeply  through  the  bed  of  the  removed  growth  and  in  the  case  of  large  openings  in  the  uterus  by 
buried  catgut  sutures  applied  in  layers.  The  peritoneal  edges  must  be  carefully  approximated  so 
as  to  diminish  the  risk  of  subsequent  adhesions  of  intestine  or  omentum. 


RKTRODICVIATIONS  1 29 

variety,  it  may  be  (lifficult  to  deliver  the  uterus  into  the  vagina.  Under 
such  circumstances,  however,  the  vaginal  method  is  not  difficult  if 
hysterectomy  be  chosen.  wShould  tumor  or  tumors  he  of  such  dimen- 
sion that  we  cannot  get  uterus  into  the  vagina,  we  have  to  enucleate 
them  while  the  uterus  is  still  partly  in  the  peritoneal  cavity. 

Subserous  myomata  of  the  anterior  uterine  wall  are  grasped  by 
forceps  before  delivery  of  the  uterine  fundus,  and  are  removed.  We 
then  attack  the  myomata  lying  higher  along  the  uterine  fundus  and 
the  myomata  of  the  posterior  corpus  wall. 

Interstitial  or  submucous  myomata  of  the  anterior  uterine  wall  may 
be  exposed  through  division  of  the  latter  and  removed  by  enucleation 
or  morcellement.  The  same  is  done  with  myomata  of  the  posterior 
corpus  wall,  if  uterus  can  be  delivered  first.  If  not,  we  may  open 
the  uterine  cavity  by  splitting  the  anterior  wall  and  then  enter  the 
posterior  wall  from  the  mucous  side,  to  enucleate  and  remove  the 
myomata  of  the  posterior  wall  or  else  the  posterior  peritoneal  route 
is  chosen  as  the  means  of  attack. 

If,  after  splitting  the  cervix  and  uterus,  we  can  leave  sufficient 
good  tissue  behind,  we  may  then  be  able  to  preserve  a  uterus.  If  we 
have  to  split  the  cervix  and  are  obliged  to  do  enucleation  or  morcelle- 
ment, it  is  often  difficult  to  save  the  uterus.  If  we  are  able  to  bring 
the  uterus  into  the  vagina  at  first,  we  can  then,  as  a  general  rule,  save 
the  uterus  if  so  desired. 

All  in  all,  whether  done  through  vagina  or  abdomen,  enucleation 
of  larger  myomata  is  more  dangerous  than  hysterectomy.  Enuclea- 
tion is  advisable  only  where  future  conception  is  an  important  matter. 

RETRODEVIATIONS. 

Vaginal  celiotomy  is  used  very  extensively  for  the  correction  of 

movable  retroflection  and  retroversion,  especially  when  dealing  with 

slightly  involved  adnexa  or  sterility  without  apparent  cause. 
9 


130  VAGINAL   CELIOTOMY 

In  fixed  retroflexion  and  retroversion  and  in  retroflexion  with  dis- 
eased adnexa,  especially  when  adhesions  are  present,  the  correction  of 
the  uterine  dislocation  is  of  secondary  importance.  The  disease  of 
the  adnexa  and  the  peritoneal  condition  are  the  elements  of  impor- 
tance, hence  the  discussion  of  this  question  appears  elsewhere. 

The  methods  used  are  vesical  suspension,  vaginal  suspension, 
vaginal  fixation,  shortening  of  the  round  ligaments  and  fixation  of 
the  round  ligaments  to  the  anterior  wall  of  the  uterus.  This  method 
of  approach  comes  into  competition  with  the  Alexander-Adams 
operation  and  with  the  various  abdominal  operations  of  shortening 
the  round  ligaments,  fixing  the  round  ligaments,  shortening  the  utero- 
sacral  ligaments,  fastening  the  round  ligaments  to  the  anterior  wall 
of  the  uterus,  ventral  suspension  and  fixation,  and  Gilliam's  admirable 
operation.  In  my  opinion  the  Alexander-Adams  operation  meets 
all  indications  for  movable  retroversion  and  flexion  with  normal 
adnexa  except,  perhaps,  when  the  uterus  is  large  or  descended,  or 
in  case  of  congenital  retroflexion  with  long  uterus  and  short  anterior 
vaginal  wall. 

With  a  uterus  in  retrodisplacement  through  posterior  parametritis, 
the  Alexander-Adams  operation  and  the  other  operations  should  be 
combined  with  a  transverse  incision  in  the  cul  de  sac  of  Douglas, 
to  be  sewed  longitudinally. 

A  selection  from  these  various  methods,  whether  by  the  abdomen 
or  vagina,  is  one  of  choice.  It  may  be  said,  however,  that  vaginal 
celiotomy  has  this  advantage  over  the  Alexander-Adams  operation 
in  that  it  permits  of  desired  exploration  and  is  readily  carried  out 
where  an  abdominal  incision  does  not  seem  warranted  because  of 
insufficiently  marked  abdominal  and  pelvic  symptoms,  or  when  there 
is  absolute  refusal  on  the  part  of  a  patient  to  submit  to  such  an  ordeal 
in  cases  with  sufficient  indications,  such  indications,  however,  not 
including  the  appendix.  The  mortality  by  these  various  methods 
is   probably   about    the   same.     An    important   difference,    however, 


RETRODEVIATIONS  I31 

concerns  the  subsequent  difliculties  which  may  be  encountered  in 
labor  and  the  clement  of  recurrence  of  the  displacement.  In  avoiding 
dirticuh}-  in  labor  after  alxlominal  operation,  I  believe  that  ventral 
fixation  of  the  round  ligaments  (Gilliam)  meets  the  indications,  even 
in  cases  of  large  uteri  with  descent,  if  the  alxlominal  wall  is  not  too 
lax,  and,  more  particularly,  if  there  is  a  retrodisplacemefit  due  to 
posterior  ])arametritis,  which  latter  condition  demands  correction,  and 
in  cases  of  long  uterus  and  short  anterior  wall  with  congenital 
retroflexion.  Danger  of  dystocia  in  labor  is  absent.  Objection  is 
made  to  vaginal  attachment  of  the  uterus  because  of  the  possibility 
of  difficulties  in  labor.  Vaginal  fixation  of  the  uterus  should  never  be 
done  in  women  who  may  become  pregnant  without  exsecting  part  of 
the  tubes.  It  may  be  said  that  if  the  incision  in  the  vesico-uterine 
peritoneal  fold  be  sewn  before  the  attaching  sutures  are  tied,  so  that 
a  suspension  and  not  a  fixation  is  done,  the  element  of  danger  in 
labor  is  almost  eliminated.  If  the  lower  part  of  the  uterus  is 
attached,  danger  is  not  present  even  if  fixation  takes  place.  With 
vaginal  shortening  of  the  round  ligaments,  with  vaginal  fixation  of 
the  round  ligaments  to  the  anterior  wall  of  the  uterus,  dystocia  in 
labor  is  out  of  the  question.  Therefore  the  selection  of  the  method 
is  one  of  individual  choice  and  there  is  certainly  no  unanimity  on  this 
question. 

It  may  be  of  interest  to  trace  the  development  of  the  various 
vaginal  operations  from  the  first  suggestion  made  by  Sanger  on. 

Sanger  said  ''We  may  obtain  a  direct  action  on  a  previously  ante- 
verted  corpus  uteri  through  the  medium  of  a  transverse  separation 
of  the  vaginal  fornix,  through  opening  of  the  plica  anteriorly  and 
fixation  of  the  corpus  uteri  with  silver  thread  to  the  vagina,  the  wound 
then  being  united  longitudinally  whereby  the  collum  at  the  same 
time  is  forced  backward  into  its  normal  position,  or  by  introducing 
the  index  finger  into  the  dilated  uterus  and  passing  through  a  silver 
thread  from  the  anterior  fornix  without  opening  the  same."     Schiicking 


132  VAGINAL   CELIOTOMY 

was  the  first  to  introduce  a  curved  needle  into  the  uterus  and  pierce 
its  anterior  wall  at  the  fundus  and  pass  it  out  between  the  uterus  and 
the  bladder  into  the  anterior  fornix.  The  needle  was  then  threaded 
with  a  strong  silk  thread  and  drawn  back,  the  two  ends  of  the  suture 
which  extended  out  at  the  anterior  fornix  and  the  external  os  were 
brought  firmly  together  and  tied.  The  uterus  was  then  held  in  decided 
anteflexion  until  its  peritoneal  covering  united  to  the  peritoneum 
i.e.  the  vesico-uterine  plica.  Frequent  injuries  to  the  bladder  led  to 
modifications  which  followed  the  other  of  Sanger's  suggestions  with 
the  purpose  of  getting  the  bladder  out  of  the  way. 

Diihrssen  and  others  in  their  early  operation  on  movable  retro- 
flexion and  retroversion  per  vaginam  did  not  open  the  vesico-uterine 
fold  of  peritoneum;  they  simply  pushed  the  bladder  off  from  the  collum 
and  the  uterus  and  fixed  that  area  of  the  uterine  wall  somewhat  above 
the  internal  os  to  the  vagina  by  passing  a  suture  into  the  uterus  through 
the  unopened  plica  (Fig.  38).  This  method  gave  no  permanent  results 
and  Diihrssen  later  opened  the  vesico-uterine  fold  of  the  peritoneum 
in  order  to  fix  the  fundus  uteri  itself  directly  to  the  vaginal  wall. 

At  this  early  period  in  the  development  of  vaginal  fixation  of  the 
uterus,  it  was  the  general  plan  after  opening  the  pHca  to  fix  the  area 
of  the  uterus  just  above  the  level  of  the  internal  os  to  the  edges  of 
the  vaginal  incision  which  was  frequently  made  in  a  longitudinal 
direction.  Fixation  of  the  area  just  above  the  level  of  the  internal 
OS  was  practised,  because  it  was  not  necessary  to  dehver  the  uterus 
and  because  this  was  the  highest  area  readily  accessible.  Mackenrodt 
divided  the  anterior  vaginal  wall  from  the  portio  almost  up  to  the 
urethra.  He  separated  the  vaginal  wall  from  the  bladder  and  pushed 
the  bladder  up  and  freed  it  from  the  cervix.  He  then  fastened  the 
bladder  with  several  catgut  sutures.  Then  fixation  sutures  were 
passed  through  the  edges  of  the  vaginal  incision  and  through  the 
anterior  wall  of  the  collum  and  uterus,  as  a  result  of  which  this  area 
of  the  uterus  was  fixed  to  the  anterior  wall  of  the  vagina.     The  bladder 


RITRODKVIATIONS 


^33 


Fig.  38. — The  first  attempts  at  vaginal  attachment  of  the  uterus  were  made  with  the  aid  of  a 
transverse  incision  in  the  anterior  fornix  and  separation  of  the  bladder  from  the  cervix  and 
uterus,  so  that  the  vesico-uterine  fold  of  peritoneum  was  brought  into  view.  One  or  more  sutures 
were  then  passed  through  the  edge  of  the  vaginal  incision  and  then  through  the  uterus,  passing 
through  the  unopened  plica.  The  transverse  vaginal  incision  was  sewn  in  a  longituchnal  manner. 
Retrodeviation  recurred  in  these  cases. 


RETRODFA'IATIOXS 


135 


M  "^ 

^     t^ 

s 

^ 

1 

m 

r 

1^ 

/ 

\l| 

^  k 

Fig.  30. — The  method  adopted  by  Martin  included  a  longitudinal  incision  in  the  anterior 
fornix,  separation  of  the  bladder  from  the  vaginal  wall  and  from  the  cer\ax  and  uterus,  opening  of 
the  plica  and  the  passing  of  sutures  through  the  margin  of  the  vaginal  incision,  through  the  anterior 
peritoneal  fold,  through  the  uterus,  and  out  in  the  corresponding  fashion.  The  lower  sutures 
passed  through  the  margin  of  the  vaginal  incision  and  through  the  anterior  wall  of  the  cervix  in 
the  area  from  which  the  bladder  had  been  separated  and  pushed  up. 


RICTRODEVIATIONS 


137 


Fig.  40. — With  the  aid  of  a  transverse  incision  in  the  anterior  fornix,  sometimes  amplified 
by  a  short  longitudinal  incision,  the  bladder  was  pushed  back  from  the  cervix  and  uterus  by 
Diihrssen.  The  plica  was  opened  in  a  longitudinal  fashion  and  fixation  sutures  were  passed 
through  the  edge  of  the  vaginal  incision  and  then  the  fundus  of  the  uterus,  the  peritoneal  fold  not 
being  interposed.  This  produced  a  sero-fibrous  fixation  of  the  acutely  flexed  fundus  and  caused 
dystocia  in   labor. 


Ri;rR(ji)i:viATiONS 


139 


^ 


Fig.  41. — To  avoid  dystocia  in  labor  in  consequence  of  the  firm  union  resulting  from  the 
method  depicted  in  figure  40,  Diihrssen  passed  one  or  more  sutures  through  the  vaginal  edge, 
through  the  peritoneum,  then  through  the  uterus,  then  out  through  the  peritoneum  and  the 
vaginal  edge.  Before  tying  this  silkworm-gut  suture  or  sutures,  the  longitudinal  incision  in  the 
peritoneum  was  sewn.  The  result  avoided  dystocia  in  labor,  for  the  attachment  of  the  uterus  to 
the  vagina  is  bv  means  of  a  sero-serous  union. 


Ri:'i'R()i)i;vrATiONS  141 

which  was  ])ushe'tl  forward  and  upward  was  not  affected  by  the  uterus 
and  the  uterus  remained  firmly  fixed  anteriorly.  The  majority  of 
the  operators  in  order  to  practise  this  method  of  fixation  of  the  lower 
area  of  the  uterus  used  the  longitudinal  incision  and  did  not  find  it 
necessary  to  deliver  the  uterus  into  the  vagina  (Pig.  39).  Duhrssen 
who  used  the  transverse  incision  and  who  fixed  the  higher  areas  of 
the  uterus  had  to  develop  more  of  the  uterus  and  even  to  deliver  it 
into  the  vagina  to  perform  his  operation,  and  later  increased  the 
extent  of  his  incision  because  of  his  original  efforts  in  the  direction 
of  intraperitoneal  operations  especially  on  the  adnexa.  The  fixation 
of  the  fundus  resulted  in  an  unusually  firm  union,  a  too  firm  union 
of  the  acutely  anteflexed  fundus  and  produced  disturbances  in  labor 
(Fig.  40).  To  avoid  this,  Duhrssen  insisted  subsequently  on  the 
sewing  of  the  incision  in  the  plica  before  tying  the  attaching  sutures, 
which,  according  to  the  new  modification,  now  passed  through  the 
vagina,  peritoneum,  fundus,  peritoneum,  vagina  (Fig.  41).  The 
transverse  incision  in  the  vagina  was  sewed  in  a  longitudinal  manner. 

With  the  original  transverse  incision  of  Duhrssen,  it  is  easy  to 
do  a  vaginal  fixation  without  delivering  the  uterus,  but  difficult  to 
get  the  uterus  into  the  vagina  except  in  the  case  of  multiparse.  When 
the  uterus  is  so  delivered,  even  in  the  case  of  multiparse,  little  room 
is  left  for  extracting  the  adnexa  or  for  operating  on  them.  Diihrssen 
then  added  a  longitudinal  incision  to  the  transverse.  As  the  indica- 
tions for  extracting  the  uterus  into  the  vagina  broadened  in  order  to 
remove  fibroids,  to  perform  operations  on  the  adnexa  including  ectopic 
gestation,  the  fornix  incisions  were  made  more  extensive  by  all 
surgeons. 

In  fixing  the  upper  part  of  the  fundus  to  the  transverse  incision 
as  Duhrssen  did,  the  uterus  became  acutely  flexed.  To  avoid  trouble 
in  pregnancy  the  peritoneum  was  made  use  of  and  a  suspension  was 
performed.  As  the  indications  developed  for  fixing  the  uterus  with- 
out any  flexion,  with  the  definite  purpose  of  so  sewing  the  fundus 


142  VAGINAL   CELIOTOMY 

as  to  support  the  bladder  and  remove  the  latter  from  extensive  contact 
with  the  vaginal  wall,  especially  in  non-bearing  women,  the  fundus  was 
fixed  higher  and  higher  on  the  anterior  vaginal  wall  and  the  longitudinal 
incision  became  continually  of  increased  length. 

If  the  uterus  is  attached  by  fixation  or  suspension  sutures  which 
pass  through  the  uterus  at  the  lower  part  of  the  fundus  the  danger 
in  pregnancy  is  sHght,  even  if  fixation  results  instead  of  suspension. 

It  is  advisable,  if  there  be  no  cystocele,  to  attach  only  a  definite 
area  of  the  uterus  somewhat  above  the  level  of  the  internal  os  to  the 
edges  of  the  longitudinal  incision  in  the  vagina  by  the  method  of 
suspension,  to  close  the  plica  and  dystocia  in  labor  is  avoided. 

HOW  TO  PASS  UTERINE  SUSPENSION  OR  FIXATION  SUTURES. 

If  the  peritoneum  is  not  to  be  sewn  again  after  any  attempted 
operation  a  transverse  opening  is  a  good  one.  A  transverse  opening, 
however,  may  be  closed  also.  Always  close  the  plica  if  pregnancy 
is  possible.  A  transverse  incision  in  the  peritoneum  does  not  lend 
itself  readily  to  a  vaginal  suspension  operation  unless  the  lowest  area 
of  the  fundus  is  to  be  attached  (Fig.  39,  Martin). 

The  plica  should  be  incised  longitudinally  as  far  as  desired  if 
it  is  intended  to  sew  it  again  after  operation.  It  is  wise  then  to  catch 
the  upper  end  of  the  plica  incision  by  forceps  or  catgut  sutures.  This 
longitudinal  opening  with  its  lateral  edges  may  obstruct  extraction 
of  the  fundus  and  adnexa  and  should  be  especially  long  in  nulliparae. 

To  deliver  the  uterus  a  speculum  is  introduced  into  the  peritoneal 
cavity,  the  cervix  is  pushed  back  by  the  posterior  retractor,  or  with 
large  vagina  by  cervix  volsellum,  and  the  anterior  wall  of  the  uterus 
is  grasped  by  tenaculum  forceps  applied  in  succession  higher  and 
higher  until  the  fundus  is  grasped  and  delivered  by  rotatory  or  side- 
to-side  motions,  which  in  the  case  of  a  large  uterus  brings  one  horn 
and  then  the  other  horn  of  the  uterus  through  the  plica  pillars. 


RETRO])KVIy\TK).\S  I43 

It  is  always  advisable  to  clcli\'L'r  the  uterus  into  the  vagina.  This 
is  easy,  if  there  are  no  adhesions,  if  the  ligamentum  infundibulo- 
pelvicum  is  long,  and  if  the  upper  ]jart  of  the  broad  ligament  is  not 
sclerosed.  It  is  then  easy  to  (leli\'er  non-adherent  tubes  and  ovaries. 
If  any  of  the  above-mentioned  conditions  prevail,  dehvery  of  the 
tubes  and  ovaries  is  more  diflkult.  It  is  more  difficult  to  dehver 
a  large  uterus  if  the  ])lica  incision  has  been  a  longitudinal  one  than 
if  the  incision  has  been  a  transverse  one.  While  the  uterus  is  being 
delivered  into  the  vagina  through  a  longitudinal  incision  in  the  perit- 
oneal plica,  the  lateral  margins  of  this  peritoneal  plica  are  put  on 
the  stretch,  especially  so,  since  the  anterior  vaginal  speculum  is  intro- 
duced to  lift  the  bladder  up  and  out  of  the  way.  The  uterus  must 
then  be  delivered  between  these  firm  peritoneal  pillars  and  this 
manipulation  is  frequently  not  simple.  In  replacing  the  uterus  these 
peritoneal  pillars  often  obstruct  the  ready  return  of  the  body  of  a 
large  uterus  into  the  pelvic  cavity.  Unless  the  peritoneal  edges 
either  at  the  upper  end  or  laterally,  or  both,  are  held  by  forceps  or 
ligatures,  the  body  of  the  uterus  in  being  pushed  back  does  not  pass 
readily  through  the  incision.  Also,  if  the  edges  of  the  plica  incision 
are  not  held  by  forceps  it  is  difiticult  to  find  it  when  desirous  of  passing 
the  suspension  sutures. 

In  order  to  avoid  subsequent  disturbances  in  labor  through  sewing 
of  the  uterus  to  the  vagina,  three  methods  are  possible:  the  vesico- 
suspension  of  the  uterus,  vagino-suspension,  and  shortening  of  the 
round  ligaments.  Suspension  is  done  by  Diihrssen  in  two  ways: 
(a)  Either  one  or  two  catgut  sutures  are  passed  through  the  upper 
part  of  the  anterior  wall  of  the  uterus  and  the  bladder  peritoneum. 
{b)  A  silkworm-gut  suture  is  passed  through  the  upper  part  of  the 
uterus  and  the  bladder  peritoneum  and  the  anterior  vaginal  wall 
and  is  removed  in  six  weeks.  With  either  of  these  modifications 
the  greatest  stress  is  to  be  laid  on  the  special  suture  of  the  peritoneal 
opening.     This  peritoneal  union  is  firm  enough  to  hold  the  uterus 


144  VAGINAL    CELIOTOMY 

in  anteversion,  and  loose  enough  to  be  stretched  by  the  pregnant 
uterus  without  annoyance.  This  is  proven  by  over  loo  normal  labors 
which  Dlihrssen  observed  after  the  second  modification. 

If  the  sutures  pass  only  through  the  uterus  and  bladder  peritoneum 
(Fig.  42-43)  any  later  change  which  actively  pulls  the  uterus  backward 
can  lead  to  a  recurrence  of  the  retro-flexio.  Hence  this  method  of 
vesico-suspension  is  indicated  only  for  very  movable  retroflexion. 
(In  that  case,  it  is  advisable  to  adhere  to  the  transverse  fornix  incision 
with  a  small  longitudinal  incision  and  not  separate  the  bladder  too 
thoroughly  from  the  anterior  vaginal  wall;  for  if  this  were  done  the 
uterus,  with  its  tendency  to  retroflex,  would  easily  pull  the  whole 
bladder  with  it.) 

After  opening  the  phca,  several  silk  sutures  are  passed  through 
the  vaginal  wall  ne^r  the  urethra,  then  through  the  peritoneum,  then 
through  the  anterior  uterine  wall  2  cm.  above  the  internal  os,  then 
through  the  peritoneum,  and  finally  through  the  right  vaginal  edge 
(Fig.  44).  To  avoid  too  firm  union,  the  incision  in  the  plica  is  first 
closed  by  continuous  suture.  The  union  of  the  bladder  peritoneum 
to  the  anterior  vaginal  wall  furnishes  a  fixed  point  for  the  attach- 
ment of  the  uterine  wall.  The  peritoneum  may  be  united  by  special 
suture  to  the  serous  covering  of  the  uterus,  or  this  may  be  accom- 
plished by  this  same  continuous  running  suture,  which  is  made  to 
catch  the  anterior  uterine  wall  (Fig.  46). 

As  a  result  of  this  operation,  the  lower  part  of  the  uterine  fundus 
just  above  the  internal  os  is  attached  to  any  desired  point  of  the 
anterior  vaginal  wall.  The  space  between  the  attached  point  and 
the  upper  part  of  the  fundus  forms  a  recess  in  which  rests  the  bladder 
which  should  have  been  displaced  upward  and  removed  more  or 
less  thoroughly  from  contact  with  the  vaginal  wall.  The  fundus, 
whenever  it  tends  to  move  backward,  through  distention  of  the  bladder 
or  for  other  reasons,  exerts  tension  on  the  attached  part  of  the  vaginal 
wall  and  pulls  it  upward  and  backward. 


ri;trc)I)i:\iations 


H5 


Fig.  42. — An  anatomical  representation  of  the  inverted  ± -shaped  vaginal  incision, 
with  thorough  separation  of  the  bladder  from  the  cervix  and  uterus  and  from  the  anterior  vaginal 
wall,  so  that  the  bladder  is  pushed  up  almost  out  of  view.  The  longitudinal  incision  in  the  perit- 
oneal plica  is  shown,  and  through  it  is  seen  the  anterior  wall  of  the  uterus.  Three  artery  forceps 
are  attached  to  the  two  anterior  vaginal  flaps.  The  one  long  artery  forceps  is  attached  to  the 
upper  end  of  the  incisid  peritoneal  plica.  The  uterus  may  be  united  to  the  peritoneal  pUca  alone 
(vesico-suspension)  or  to  the  anterior  vaginal  flaps  with  the  peritoneal  plica  intervening  (vagino- 
suspension)  or  to  the  vaginal  flaps  directly,  by  bringing  the  uterus  out  through  the  peritoneal  plica 
into  intimate  contact  with  the  anterior  vaginal  flaps  (vagino-fixation). 


RETRODEVIATIONS 


147 


Fig.  43. — ^Vesico-fixation  of  the  uterus.  The  anterior  wall  of  the  uterus  is  to  be  attached  to  the 
peritoneum  which  has  been  dissected  away  from  the  posterior  wall  of  the  bladder.  The  longitudi- 
nal incision  into  the  peritoneal  plica  must  be  closed  with  continuous  running  suture.  This  is 
shown  by  the  needle  and  catgut  with  which  the  closing  of  the  plica  incision  is  being  done  from 
below  upward.  The  uterus  is  held  in  the  desired  position  by  a  pro\isional  suture  in  its  anterior 
wall.  The  edges  of  the  peritoneal  plica  are  brought  into  relief  by  three  provisional  sutures,  two 
applied  to  the  lateral  margin  and  one  at  the  upper  angle  of  the  incision  in  the  plica.  The 
bladder  is  seen  just  below  the  highest  artery  forceps.  As  a  rule,  the  best  results  are  obtained 
in  vesico-suspension  if  the  bladder  is  not  thoroughly  separated  from  its  attachment  to  the  anterior 
wall  of  the  vagina. 


RETRODEVIATIONS 


149 


I 

1   ''  jH. 

m4 

j 

£!^ 

K 

i&^s^== 

w.  "^"flE 

r-^^3L 

/; 

^Kii^^^^^^B^  i  -U 

h  / 

i. 

/ 

r 

\ 

IL       /' 

\ 

Fig.  44. — ^Vagino-suspension  of  the  lower  part  of  the  uterus.  The  attaching  sutures  pass 
through  the  upper  part  (or  any  part)  of  the  vaginal  flaps,  through  the  lateral  borders  of  the  perit- 
oneal plica  and  through  the  lowest  area  of  the  uterine  body.  The  uterus  is  held  forward  by  pro- 
visional suture  and  the  edges  of  the  peritoneal  pUca  are  brought  into  rehef  by  three  provisional 
sutures.  The  incision  in  the  peritoneal  plica  must  of  course  be  sewed  as  in  figure  43  and  figure 
46  before  the  attaching  sutures  are  tied. 


RKT  RODE  VIATION  S 


151 


Fig.  45. — Vagino-suspsnsion  of  the  upper  area  of  the  uterus.  Sutures  are  passed  through 
the  edge  of  the  vaginal  flap  on  one  side,  through  the  edge  of  the  peritoneal  plica  of  the  same 
side,  through  the  fundus  uteri,  and  then  through  the  peritoneum  and  vaginal  flap  of  the  other 
side.  The  incision  in  the  peritoneal  plica  is  sewn  before  these  sutures  are  tied.  The  fundus  is 
held  forward  by  a  volsellum.  The  flap  edges  and  the  edges  of  the  peritoneal  plica  incision  are 
brought  distinctly  into  view  by  applied  forceps. 


RETRODEVIATIONS  153 

If  tluMT  is  a  tendency  to  cystocele  and  if  care  is  taken  to  close  the 
plica  the  bladder  is  kept  more  thoroughly  and  more  permanently 
awav  from  contact  with  the  anterior  \'a^inal  wall  if  the  fundus  of 
the  uterus  is  attached  to  the  anteri(jr  vaginal  flajjs  (P'ig.  45).  'Jdiis 
holds  the  fundus  more  anteriorly,  it  is  less  inliuenced  by  distention 
of  the  bladder  and  subsequent  development  of  a  retroversion  or  retro- 
flexion is  prevented. 

The  suspension  sutures  may  be  passed  either  before  or  after  the 
uterus  is  replaced.  If  the  fundus  of  the  uterus  is  to  be  attached, 
the  sutures  may  be  passed  before  replacing  the  fundus.  In  passing 
these  sutures  before  replacing  the  uterus,  the  anterior  speculum  should 
be  taken  out  and  the  ligatures  should  be  passed  through  one  vaginal 
flap,  vesico-uterine  peritoneum,  serosa  and  uterus,  then  out  through 
vesico-uterine  peritoneum  and  the  opposite  vaginal  flap.  The  perit- 
oneum is  sewed  after  the  uterus  is  replaced  into  the  pelvis  (Fig.  46). 
There  can  be  no  disturbance  in  labor  if  the  peritoneal  fold  is  sewn. 
If  the  round  ligaments  are  shortened,  or  if  they  are  sewed  to  the 
anterior  wall  of  the  uterus,  closure  of  the  peritoneal  fold  is  easy.  As 
a  general  rule,  the  plica  should  be  sewed.  If  the  lower  part  of  the 
uterus  is  to  be  attached  the  sutures  may  be  readily  passed  after  re- 
placing the  fundus;  a  volsellum  applied  to  the  lower  area  of  the 
fundus  marks  the  part  on  the  uterine  wall  through  which  the  sutures 
are  to  pass. 

It  has  been  claimed  that  this  method,  when  carefully  done,  avoids 
dystocia  in  labor.  Personally,  I  hesitate  to  make  too  high  an  attach- 
ment of  the  fundus,  even  if  only  a  suspension  be  done,  in  any  case  in 
which  future  pregnancy  is  possible.  As  a  matter  of  fact,  by  far  the 
largest  number  of  such  operations,  where  cystocele  is  present,  are 
done  in  women  past  the  child-bearing  age  or  in  women  who  have  a 
sufhciently  large  family.  In  such  instances,  fixation  of  the  fundus 
to  the  anterior  vaginal  wall  is  done  (Fig.  50).  The  incision  in  the  perit- 
oneal plica  is  not  sewed,  and  excision  of  a  definite  area  of  either  tube 


154  VAGINAL   CELIOTOMY 

prevents  further  conception.  In  such  cases  the  operation  is  done  more 
readily  through  a  transverse  incision  in  the  phca  (see  Fig.  30). 

In  doing  a  vaginal  shortening  of  the  round  ligaments,  an  operation 
which  is  inappropriately  termed  a  vaginal  Alexander-Adams,  the 
round  ligament  on  either  side  should  be  grasped  with  forceps  or  by 
having  a  suture  pass  through  it  about  i  1/2  inches  away  from  the  uterus. 
This  may  be  done  when  the  uterus  has  been  pulled  forward  under  the 
anterior  speculum,  but  not  into  the  vagina.  This  position  of  the 
uterus  allows  the  round  ligament  to  be  pulled  out  so  that  it  may  be 
readily  sewed.  It  is  advisable  to  deliver  the  uterus  in  these  cases 
for  inspection  of  the  adnexa.  If  this  is  done  the  upper  part  of  the 
broad  ligament  is  put  on  the  stretch  and  it  is  difficult  to  pull  out  the 
round  ligament  in  sufficient  length  to  shorten  it.  The  ligamentum 
rotundum  should  be  caught  by  suture  or  clamp  and  then  the  uterus 
should  be  replaced  toward  the  peritoneal  cavity  which  so  reheves 
the  tension  on  the  upper  part  of  the  broad  ligament  and  the  round 
ligament  that  the  latter  projects  into  the  vagina  sufficiently  to  be 
properly  shortened.  The  ligament  may  be  shortened  by  simply 
having  two  adjoining  surfaces  sewed  together  by  interrupted  sutures 
over  a  distance  of  i  1/2  to  2  1/2  inches  or  more,  or  else  a  duplication 
is  made,  and  the  round  ligament  is  sewed  to  the  anterior  wall  of  the 
uterus  by  interrupted  sutures  (Fig.  47).  This  latter  method  is  the 
better  of  the  two. 

In  cases  where  pregnancy  is  not  to  take  place,  or  when  pregnancy 
is  excluded  by  disease  of  the  adnexa  or  by  excision  of  the  tubes, 
the  uterus  is  brought  into  intimate  contact  with  the  raw  surfaces  of 
the  uterine  vaginal  flaps  without  intervention  of  the  vesico-uterine 
fold  of  the  peritoneum  (Fig.  52).  Hence,  in  performing  this  opera- 
tion it  is  not  necessary  to  make  a  longitudinal  incision  into  the  vesi- 
co-uterine fold  to  enter  the  peritoneal  cavity,  a  simple  transverse 
incision  suffices. 

The  sewing  of  the  uterus  to  the  vagina  and  placing  it  underneath 


RETRODEVIATIONS 


155 


Fig.  46. — In  all  operations,  excepting  vagino-fixation,  the  incision  in  the  peritoneal  plica 
should  be  carefully  sewn  before  the  attaching  sutures  are  tied  or  on  completion  of  any  intraperit- 
oneal operation.  As  this  incision  in  the  peritoneal  plica  is  being  sewn,  the  needle  may  be  made 
to  pass  at  the  same  time  through  the  anterior  wall  of  the  uterus  and  thus  make  the  sero-serous 
union  to  the  uterus  more  certain.  The  plica  incision  may  be  closed  from  below  upward,  or 
from  above  downward. 


RKTROni:\IATIO\S 


157 


Fig.  47. — Eilher  before  the  uterus  is  completely  delivered  through  the  vagina  or  after  the 
uterus  has  been  delivered  and  then  pushed  back  so  as  to  diminish  the  tension  on  the  broad  liga- 
ments, each  round  ligament  is  drawn  forward  by  a  long  artery  forceps  and  sewed,  (a)  as  on  right 
side  of  the  drawing,  by  interrupted  silk  sutures  which  unite  the  two  surfaces  of  the  duplication 
of  the  ligament,  or  (6)  as  on  left  side,  where  the  silk  sutures  which  unite  the  two  surfaces  of  the 
duplication  pass,  at  the  same  time,  through  the  anterior  surface  of  the  uterus.  During  this 
manipulation  the  uterus  is  held  in  the  position  shown  by  a  volsellum  or  by  a  provisional  suture 
attached  to  the  uterine  wall. 


RETRODEVIATIONS  1 59 

Uk'  bladder  is  a  ^urcat  change  in  the  normal  relations.  Tt  is  rarely, 
however,  that  any  annoyance  in  the  bladder  function  is  experienced. 
A  few  days  after  the  operation  there  is  some  chTficulty,  Ijut  shortly 
after  the  anno^-ances  are  almost  nil.  Fixation  holds  the  uterus 
permanently  in  its  new  ])osition,  the  union  between  the  uterus  and 
vagina  is  firm  and  serofibrous.  The  anterior  wall  of  the  uterus  is 
held  against  the  vagina  in  pregnancy  so  firmly  that  the  natural  up- 
ward extension  of  the  fundus  would  be  prevented.  The  obstacles 
in  labor  through  such  malposition  of  the  uterus,  of  the  cervix,  and 
of  the  fetus  are  so  marked  that  vaginal  fixation  should  never  be  done 
in  women  who  may  become  pregnant. 


CYSTOCELE  AND  VAGINO-FIXATION. 

The  methods  usually  employed  in  the  treatment  of  cystocele  are 
those  of  an  ordinary  simple  anterior  colporrhaphy,  or  a  more  extensive 
anterior  colporrhaphy,  so  extensive  that  the  entire  width  of  the  anterior 
vaginal  wall  is  removed  and  brought  together  to  form  a  sharp-angled 
union  of  the  lateral  vaginal  walls.  The  simple  form  of  anterior 
colporrhaphy  would  be  productive  of  better  results  if  it  were  associated 
with  a  complete  separation  of  the  bladder  from  its  utero-vaginal 
seat.  The  bladder  shrinks  of  its  own  accord,  when  so  separated,  as 
a  result  of  its  natural  elasticity,  and  a  good  sized  area  may  then  be 
more  readily  taken  from  the  anterior  vaginal  wall,  and  part  of  the 
anterior  vaginal  wall  may  then  be  attached  to  the  former  cervico-uterine 
situation  of  the  bladder,  so  as  to  keep  the  latter  organ  up  out  of  the  way. 
This  can  be  very  successfully  accomplished  by  the  use  of  the  inverted 
1 -incision,  associated  with  complete  separation  of  the  bladder.  Any 
desired  area  of  either  flap  is  resected  and  then  the  flaps  are  united  by  inter- 
rupted or  running  catgut  sutures.  The  sutures  which  unite  the  lower 
area  of  the  flaps  may  at  the  same  time  pass  through  the  lower  area  of 
the  uterus  below  the  vesico-uterine  peritoneum  and  through  the  upper 
area  of  the  cervix.  In  this  operation  the  bladder  may  be  reefed  a 
trifle,  and  may  be  united  by  two  or  more  catgut  sutures  to  a  higher 
area  of  the  vesico-uterine  peritoneum,  or,  to  the  anterior  sur- 
face of  the  utero-cervical  area.  The  peritoneal  cavity  may  be 
entered  and  the  fundus  uteri  sewed  to  the  vesico-uterine  plica  only. 
This,  combined  with  an  excision  from  either  flap,  is  a  combination 
of  anterior  colporrhaphy  and  vesico-suspension. 

The  very  high  vaginal  suspension  described  in  figures  44  and  45 
is  also  a  procedure  which  may  be  used.     Either  the  lower  part  of  the 

160 


CYSTOCELE    AND    VAGINO-FIXATION  l6l 

Uterus  is  LitUichcd  to  u  hij^licr  area  of  the  vaginal  ilajjs  with  intervention 
of  the  vesico-uterinc  fold  of  the  y3critoneiim  or  else  the  fundus  is  attached 
to  the  lii<i;hest  point  of  the  longitudinal  incision  in  the  anterior  vagina, 
with  intervention  of  tlie  vesico-uterine  ])eritoneum. 

An  objection  to  this  method  may  be  found  in  the  fact  that  the 
bladder  is  ke]3t  anterior  tcj  the  peritoneum  which  is  reflected  from 
its  posterior  wall,  and  this  peritoneal  fold  which  is  now  attached  to  the 
anterior  wall  of  the  vagina  limits  the  backward  displacement  and 
dilatation  of  the  bladder,  and  keeps  it  within  very  narrow  boundaries. 
This  operation  guards  against  a  subsequent  altered  position  of  the 
uterus  itself  and  permits  of  pregnancy,  according  to  Diihrssen, 
without  danger  of  dystocia.  This  limitation  of  the  excursions  of 
the  bladder  might  be  overcome  by  making  use  of  a  transverse  incision 
in  the  plica  and  then  using  this  apron  of  the  peritoneum  as  an  interven- 
ing peritoneal  fold  when  uniting  the  fundus  to  the  upper  end  of  the 
longitudinal  incision.  If  then  the  vaginal  flaps  are  united  in  their 
lower  area  without  being  sewed  to  the  peritoneum  of  the  uterus,  too 
firm  fixation  of  any  part  of  the  uterus  would  be  avoided. 

The  best  method  in  women  who  are  no  longer  to  bear  children, 
in  my  experience,  consists  in  so  placing  the  bladder  that  it  is  put 
backward  into  the  peritoneal  cavity,  resting  upon  the  posterior  surface 
of  the  uterus,  and  the  uterus  is  fixed  to  the  anterior  vaginal  wall — 
acting  as  a  buffer  against  any  descent  of  the  bladder — fixing  the 
uterus  in  a  position  from  which  it  can  never  retrovert  or  markedly 
descend  or  prolapse;  for  retroversion  is  the  first  step  in  the  develop- 
ment of  a  marked  ptosis,  descensus  or  prolapsus  uteri.  The  operation 
is  an  extension  of  the  original  principle  of  Diihrssen  and  ^Nlackenrodt, 
who  originated  this  procedure  in  its  earlier  form  for  the  correction 
of  uterine  retrodeviations. 

Cystocele  in  its  real,  uncomplicated  type  is  a  true  hernia  of  the 
bladder,  with  the  uterus,  even  though  somewhat  descended,  still  in 
anteflexion    or    retroversion.     There    are    variations    from  this  type, 


1 62  VAGINAL   CELIOTOMY 

of  course,  for  with  a  very  marked  ptosis,  or  descensus  or  total  prolapse 
of  the  uterus,  there  is  more  or  less  descent  of  the  anterior  vaginal 
wall  up  to  the  extreme  degree  of  complete  eversion  of  the  vagina. 
In  these  cases,  of  necessity,  the  bladder  follows  the  downward  course 
of  the  anterior  vaginal  wall.  There  are  other  instances  in  which 
the  descent  of  the  vagina  is  more  marked  than  is  the  ptosis,  or  descent 
of  the  uterus,  so  that  in  some  cases  the  prolapsing  vagina  may  be 
the  responsible  factor  in  causing  a  retroverted  and  descending  uterus 
to  end  in  total  prolapse.  In  these  cases,  when  the  uterus  by  its  marked 
descent  fixes  our  surgical  attention  on  that  organ  mainly,  vaginal 
fixation  of  the  uterus  has,  in  the  mind  of  almost  any  one,  a  reason 
for  its  performance.  Inasmuch  as  the  operation  performed  for  that 
indication  has  as  one  of  its  most  valid  justifications  the  very  fact 
that  it  puts  the  bladder  out  of  the  way  and  prevents  forever  a  subsequent 
appearance  of  that  organ  in  the  vagina  or  beyond  the  vulva,  there 
is  no  reason  why  the  same  operation  should  not  be  done  when  the 
bladder  itself  is  the  one  organ  which  is  out  of  place. 

Vaginal  fixation  attaches  the  uterus  so  closely  to  the  anterior 
vaginal  wall  that  the  union  is  and  should  be  a  most  firm  and  unyielding 
one;  hence  in  that  event  pregnancy  should  not  be  permitted.  In  a 
goodly  proportion  of  cases,  patients  upon  whom  this  operation  is 
done  are  beyond  the  child-bearing  years.  On  the  other  hand,  a 
very  large  proportion  are  still  menstruating,  and  pregnancy  may  in 
these  cases  be  prevented  by  the  simple  step  of  resecting  a  portion 
of  either  tube.  This  step  in  no  wise  interferes  with  menstruation 
and  does  not  induce  an  artificial  menopause. 

The  present  method  is  the  result  of  years  of  experience  by  Diihrssen 
and  others,  and  has  been  sufficiently  tested  to  warrant  its  general 
acceptance  in  the  class  of  women  who  are  no  longer  to  bear  children. 

Figure  48  shows  a  typical,  well-marked  and  extreme  type  of  cystocele 
constituting  a  true  hernia  of  the  bladder  with  its  covering  of  vaginal 
mucosa  reduced  to  extreme  thinness.     The  uterus  is  in  anteversion 


CYSTOCELE    AND    VAGINO-FIXATION 


163 


■|^HHHHB|^nHMaBB|^^B 

i 

~v^ 

^H^ft 

^Ih                      V  ^^^^^^1 

H 

1 

K 

^^^^^^L^  J  ^^^^^^^^^E 

t 

^^^^  ''^^pp 

w 

H^^^Hp       ^K. 

;'5SE 

Fig.  48. — Typical  marked  extreme  type  of  cystocele  with  the  uterus  anteverted  and  not 
descended.  The  cervix  has  been  pulled  down  to  the  vulva  by  traction  on  volsella.  This  condition 
constitutes  a  real  hernia  of  the  bladder  through  the  vesico-uterine  ligaments  and  through  the 
anterior  vaginal  wall. 


CYSTOCELE    AND    VAGINO-FIXyVTION  165 

and  sliiijhtly  descended.  Tn  such  cases,  as  in  all  cases  of  anterior 
vaginal  celiotomy,  the  operation  is  begun  Ijy  a  transverse  incision 
made  usually  with  the  scissors  across  the  anterior  wall  of  the  cervix 
just  below  the  lower  border  of  the  bladder.  The  superior  lip  of  this 
incision  is  lifted  up  by  two  pairs  of  artery  forceps,  and  with  the  aid 
of  scissors  and  the  index  finger  covered  with  gauze  the  bladder  is 
thoroughly  separated  from  its  attachment  to  the  anterior  wall  of 
the  cervix  and  from  the  uterus  up  to  the  vesico-uterine  fold  of  perito- 
neum. A  longitudinal  incision  is  then  made,  beginning  at  the  middle 
of  the  transverse  incision  and  extending  up  very  close  to  the  urethra. 
This  incision  is  made  by  a  pair  of  long,  sharp-pointed  scissors,  the 
lower  blade  of  which  is  introduced  between  the  vaginal  mucosa  and 
the  bladder;  by  successive  snips  the  incision  is  extended  to  any  desired 
length.     (Figs.  18-22.) 

After  the  longitudinal  incision  has  been  made  the  two  artery  forceps 
which  have  been  applied  to  the  superior  lip  of  the  transverse  incision 
are  used  to  evert  the  vaginal  mucous  membrane,  and  dissection  of 
the  bladder  is  begun  with  a  few  snips  of  the  scissors  and  is  then 
continued  with  the  finger  or  thumb  covered  with  gauze  until  two 
very  large  flaps  result  from  complete  separation  of  its  attachment  to 
the  anterior  vaginal  wall.     (Figs.  23-27.) 

In  extreme  cases,  like  those  illustrated  by  figure  48,  the  vaginal 
mucosa  is  so  thin  that  its  separation  from  the  bladder  has  to  be  done 
with  extreme  care  with  a  very  sharp  knife.  Whereas,  ordinarily, 
separation  of  the  bladder  is  completed  in  three  minutes ;  in  a  case  like 
figure  48  it  may  take  from  ten  to  fifteen  minutes  to  carry  the  dissection 
as  far  as  illustrated  in  figure  49  in  order  not  to  injure  the  bladder, 
and  to  avoid  tearing  the  vaginal  flaps  or  leaving  islands  of  vaginal 
mucosa  behind. 

Figure  49  shows  two  flaps  produced  by  carrying  the  knife-dissec- 
tion as  far  laterally  as  necessary,  after  which  further  separation  of 
the  bladder  from  these  flaps  can  be  carried  out  with  the  aid  of  the 


1 66  '       VAGINAL   CELIOTOMY 

finger  covered  with  gauze.  The  character  and  form  of  the  connective- 
tissue  attachments  of  the  bladder  to  the  vaginal  mucosa  is  well  repre- 
sented in  figure  49.  That  this  condition  is  a  true  hernia  of  the  bladder 
is  clearly  illustrated  in  figures  48  and  49. 

After  the  bladder  has  been  thoroughly  separated,  an  anterior 
vaginal  speculum  is  introduced  underneath  the  bladder,  and  the 
bladder  is  lifted  up  out  of  the  way  and  pushed  back  of  the  symphysis. 
There  is  then  exposed  to  the  eye  the  fold  of  peritoneum  which  runs 
from  the  posterior  wall  of  the  bladder  to  the  anterior  wall  of  the  uterus, 
the  so-called  vesico-uterine  fold  of  peritoneum.  This  is  lifted  up  with 
a  pair  of  mouse-toothed  forceps,  and  with  a  pair  of  scissors  a  trans- 
verse incision  is  made  running  the  full  width  of  the  uterus  (Fig.  30). 
The  anterior  vaginal  speculum  is  then  placed  underneath  the  bladder 
and  extending  through  this  incision  in  the  peritoneum  into  the  perit- 
oneal cavity,  and  the  bladder  is  again  lifted  up  out  of  the  way  and 
placed  behind  the  symphysis.  With  the  anterior  wall  of  the  uterus 
now  clearly  exposed  to  the  eye,  several  tenaculum  forceps  are  applied 
in  succession,  and  the  fundus  is  gradually  pulled  through  this  opening 
in  the  peritoneum,  the  cervix  being  at  the  same  time  pushed  back 
over  the  surface  of  the  posterior  speculum  into  the  vagina.  When 
the  utefus  is  finally  delivered  through  the  vagina  beyond  the  vulva, 
we  have  a  picture  well  represented  by  figure  33. 

Figure  35  shows  the  space  which  exists  between  the  anterior  specu- 
lum which  holds  the  bladder  up  out  of  the  way  and  the  posterior  wall  of 
the  uterus,  the  space  through  which  any  intraperitoneal  manipulation 
upon  the  tubes  and  ovaries  must  be  carried  out.  It  illustrates  clea,rly 
the  accessibility  of  the  tubes  in  cases  where  it  is  desired  to  produce 
artificial  sterility.  This  can  be  done  by  applying  two  ligatures  about 
the  tube,  one  inch  apart,  and  then  resecting  the  intervening  area  of 
the  tube  and  burying  the  exposed  ends  under  the  peritoneum  of  the 
mesosalpinx.  Attachment  of  the  uterus  to  the  anterior  vaginal  wall 
is  then  carried  out  after  resection  of  any  desired  area  of  the  anterior 


CYSTOCKLK    A\D    VAGINO-FIXATIOX 


167 


Fig.  4g. — Two  vaginal  flaps  have  been  dissected  from  the  cystocele  by  the  inverted  ±  incision. 
The  mucosa  covering  the  most  prominent  part  of  the  cystocele  is  of  extreme  thinness  and  so  inti- 
mately connected  with  the  bladder  that  separation  can  only  be  accomplished  with  the  knife. 
The  flaps  are  to  be  dissected  still  further  in  a  lateral  direction.  The  character  of  the  connective- 
tissue  attachment  of  the  bladder  to  its  vaginal  covering  is  clearly  shown.  Because  of  the  thin- 
ness of  the  vaginal  flaps  at  their  rnedian  area,  and  because  of  the  superfluous  amount  of  tissue,  two 
semicircular  areas  are  to  be  resected  from  either  side,  so  that  thick  mucosa  remains  for  attachment 
to  the  anterior  wall  of  the  uterus.  '~ 


CYSTOCELE    AND    VAGINO-FIXATION 


169 


Fig.  50. — After  delivery  of  the  uterus  into  the  vagina,  the  anterior  speculum  is  removed,  and 
four  fixation  sutures,  two  of  silk  and  two  of  chromic  catgut,  are  passed  through  the  fundus  uteri  and 
the  edges  of  the  vaginal  flaps,  after  resection  of  the  redundant  areas  of  the  flaps.  Two  semi- 
circular areas  representing  the  superfluous  mucosa  of  the  anterior  vaginal  wall  have  been  resected 
from  either  flap,  so  that  the  remaining  vaginal  tissue  through  which  the  sutures  have  passed  fur- 
nishes thick  mucosa  for  the  attachment  of  the  uterus.  The  bladder  is  to  be  seen  above  and  pos- 
terior to  the  fundus. 


CY.STOCELE    AND    VAGINO-FIXATION 


171 


^ojs^e- 


FiG.  51. — After  the  fixation  sutures  have  been  passed  through  the  vaginal  flaps  and  the  fundus 
uteri,  the  uterus  is  pushed  back  along  the  under  surface  of  the  anterior  speculum,  while  the  cer\ix 
is  at  the  same  time  being  pulled  toward  the  vulva. 


CYSTOCELE    AND    VAGIXO-FIXATION 


173 


Fig.  52. — After  the  uterus  has  been  replaced  behind  the  vaginal  flaps,  but  not  through  the 
plica  incision,  traction  on  the  four  fixation  sutures  brings  the  anterior  wall  of  the  scarified 
fundus  into  intimate  contact  with  the  raw  surface  of  the  vaginal  fiaps.  The  bladder  now  rests 
on  the  posterior  surface  of  the  uterus.  The  character  of  the  anterior  vaginal  wall  which  now 
consists  of  only  fairly  thick  mucosa,  shows  that  a  ver}'  large  resection  of  the  flaps  of  figure  49  has 
been  made. 


CYSTOCELE    AND    VAGINO-FLXATION 


175 


Fig.  53. — The  four  fixation  sutures  have  been  tied  after  resection  of  part  of  the  anterior  flaps; 
the  two  of  silk  are  left  long.  The  remainder  of  the  longitudinal  and  the  transverse  incision  are 
sewn  with  interrupted  or  continued  catgut  sutures.  On  completion  of  the  operation,  the  vagina 
is  packed  with  iodoform  gauze  and  the  cervix  is  pushed  well  up  into  the  vagina. 


CYSTOCELE   AND    VAGINO-FIXATION  1 77 

vaginal  lla])s.  For  instance,  m(;st  of  each  flap  exposed  in  figure  49 
is  resected  so  that  the  remaining  portions  consist  of  thick  vaginal 
mucosa. 

Four  sutures  are  now  used,  two  of  twenty-day  chromic  catgut  Xo. 
3,  two  of  fairly  heavy  braided  silk.  The  sutures  are  passed  through 
the  edge  of  the  upper  part  of  the  longitudinal  incision  (after  any 
desired  resection  of  flaps  has  been  done),  then  through  the  anterior 
wall  of  the  fundus  uteri  at  its  uppermost  part,  and  then  through  the 
edge  of  the  opposite  lateral  vaginal  flap  (Fig.  50.)  The  anterior  wall 
of  the  uterus  is  then  scarified  with  a  sharp  knife  so  that  union  of  the 
uterus  to  the  raw  surface  of  the  vaginal  flaps  will  be  an  intimate  one. 
The  cervix  is  then  pulled  out  from  the  vagina  over  the  posterior  specu- 
lum and  the  fundus  is  pushed  back  along  the  under  surface  of  the  upper 
speculum  within  the  peritoneal  cavity  (Fig.  51).  Tension  is  then 
exerted  on  these  four  sutures  and  the  anterior  wall  of  the  uterus  is 
brought  closely  into  apposition  to  the  vaginal  flaps,  care  being  taken 
that  no  section  of  the  bladder  is  allowed  to  intrude  itself  between  the 
uterus  and  the  vaginal  flaps.  This  manipulation  is  illustrated  in  figure 
52.  With  the  uterus  held  in  the  position  illustrated  in  figure  52,  I 
very  often  pass  a  No.  2  chromic  suture  through  the  vaginal  flaps  and 
the  uterine  Avail  just  above  the  uppermost  of  the  four  sutures,  so  that 
if  traction  on  the  four  sutures  is  momentarily  released  no  pouch  of 
the  bladder  will  descend  to  obstruct  firm  union  while  these  four 
sutures  are  being  tied  as  illustrated  in  figure  53. 

It  can  be  seen  in  figure  53  that  the  anterior  wall  of  the  uterus  is 
firmly  attached  to  the  anterior  vaginal  wall,  and  the  bladder,  of  necessity, 
is  within  the  peritoneal  cavity  resting  on  the  posterior  wall  of  the  uterus. 
The  upper  part  of  the  longitudinal  incision  may  be  united  with  running 
catgut  suture  before  the  procedure  illustrated  in  figure  53.  As  a  rule, 
however,  the  four  fixation  sutures  bring  the  edges  of  the  vaginal  mucosa 
sufficiently  well  together.  The  edges  of  the  longitudinal  incision, 
below  the  four  fixation  sutures,  are  then  united  by  running  catgut 


178  VAGINAL   CELIOTOMY 

suture  and  then  the  transverse  incision  is  closed  as  illustrated  in 
figure  53. 

It  is  always  advisable  to  leave  a  space  in  the  transverse  incision 
through  which  a  twist  of  iodoform  gauze  may  be  introduced  to  drain 
off  any  oozing  of  blood  which  might  accumulate  between  the  lower  part 
of  the  uterus  and  the  vaginal  flaps.  The  vagina  is  then  thoroughly 
packed  with  gauze,  introduced  in  such  a  manner  that  the  cervix  is 
pushed  backward  and  upward  into  the  hollow  of  the  sacrum.  The 
gauze  is  then  removed  at  the  end  of  five  or  six  days ;  the  silk  sutures  are 
allowed  to  remain  from  four  to  six  weeks. 

It  is  always  advisable  to  catheterize  these  patients  for  four  or  five 
days,  as  slight  difficulty  in  urination  may  be  experienced,  but  generally 
for  only  a  very  short  time. 

In  many  cases  it  is  found  that  with  a  long  cervix  or  descended  uterus 
the  cervix  does  not  remain  sufficiently  high  up  and  far  back  in  the 
vagina,  so  that  a  high  amputation  of  the  cervix,  unless  the  uterus  is 
very  small,  is  very  often  an  advisable  step. 

These  drawings,  however,  simply  illustrate  the  technic  in  the  per- 
formance of  vaginal  fixation. 

TWO  POINTS  OF  IMPORTANCE  IN  THE  PERFORMANCE  OF 
VAGINO-FIXATION  FOR  DESCENSUS  UTERI. 

Vagino-fixation  of  the  uterus  attaches  the  fundus  uteri  to  the  anterior 
vaginal  wall  and  places  the  bladder  on  the  posterior  wall  of  the  uterus. 

In  order  to  perform  this  operation  to  the  greatest  advantage  to  the 
patient,  it  is  necessary  that  the  fundus  should  be  well  up  behind  the 
symphysis  and  that  the  cervix  should  be  thrown  high  up  and  as  far  back 
as  possible  toward  the  hollow  of  the  sacrum.  The  cervix  takes  this 
position  when  vaginal  fixation  is  done  to  correct  retroversions  or  retro- 
flexions which  are  not  complicated  by  elongatio  colli,  by  cystocele,  by 
descent  of  the  uterus  or  by  descent  of  the  vaginal  walls.  Then  the 
simple  operation  of  vaginal  fixation  usually  suffices  except  in  those 


VAGINO-I'IXATION    FOR    DKSCEXSUS    UTERI 


179 


Fig.  '^4. — Four  fixation  sutures,  two  of  chromic  catgut  and  two  of  silk,  bring  the  scarified 
fundus  of  the  uterus  into  apposition  with  the  anterior  vaginal  flaps  in  the  performance  of  vaginal 
fixation. 


VAGINO-FIXATION    FOR    DESCENSUS    UTERI 


i8t 


^OSS£~ 


Fig.  55. — The  fixation  sutures  which  attach  the  fundus  uteri  to  the  anterior  vaginal  flaps 
are  tied,  and  the  remainder  of  the  longitudinal  and  transverse  incision  is  united  with  continued 
or  interrupted  catgut  sutures.  The  position  of  this  uterus  shows  the  fundus  to  be  sagging  down 
into  the  vagina  and  the  cervix  to  be  dropping  down  toward  the  vulva.  On  completion  of  the  opera- 
tion the  vagina  is  thoroughly  packed  with  gauze.  Subsequent  examination  often  shows  the  cervix 
to  be  acutely  flexed  and  to  be  descended  toward  the  vuha.  This  happens  particularly  when 
simple  vagino-fixation  has  been  done,  w-ithout  resection  of  part  of  the  anterior  vaginal  flaps,  for 
descensus  uteri,  or  for  cystocele  associated  with  descensus  uteri,  with  long  uterus  and  elongatio- 
coUi.  The  drawing  shows  this  condition  in  an  exaggerated  form.  Hence  vagino-fixation  of  the 
uterus  as  the  sole  procedure  does  not  suffice  in  such  cases. 


VAGINO-FIXATION    FOR    DESCENSUS    UTERI 


183 


Fig.  56. — To  avoid  sagging  of  the  fundus  and  projection  of  the  cervix  toward  the  vulva 
part  of  each  anterior  flap  is  resected  and  a  high  amputation  of  the  cervix  is  begun  after  the 
uterine  Sxation  sutures  have  been  passed  but  not  tied.  After  a  transverse  posterior  incision, 
the  lower  lip  of  the  incision  is  grasped  by  artery  forceps  and  discloses  the  connective  tissue 
bands,  uniting  it  to  the  posterior  wall  of  the  cervix. 


VAGINO-FIXATION    FOR    DESCENSUS    UTERI 


i8s 


Fig.  57. — Upward  dissection  with  the  gauze-covered  index  linger  separates  the  vaginal  mucosa 
from  the  posterior  wall  of  the  cervix  up  to  the  cul  de  sac  of  Douglas  which  is  seen  just  beyond  the 
tip  of  the  finger. 


VAGIxXC-FlXATIOX    FOR    DESCENSUS    UTEKI 


187 


Fig.  58. — To  completely  separate  the  cervix  from  its  enveloping  mucosa,  the  bridge  of  mu- 
cous membrane  covering  the  lateral  wall  of  the  cervix  is  incised  with  scissors  and  is  peeled 
upward  with  the  gauze-covered  thumb  until  the  area  of  the  internal  os  and  the  uterine  arteries  is 
reached. 


VAGINO-FIXy\TION    FOR    DESCENSUS    UTERI 


189 


Fig.   5g. — The  cervix  is  amputated  at  a  ver}-  high  level,  often  very  near  the  lower  border  of 
the  peritoneum  covering  the  uterus. 


VAGINO-FIXATTON    FOR    DESCENSUS    UTERI 


191 


Fig.  60. — The  anterior  lip  of  the  cervix  is  grasped  with  volsellum  forceps  and  the  posterior 
part  of  the  separated  vaginal  tissue  is  united  to  the  cervix  by  three  chromic  catgut  sutures  passed 
deeply  through  the  structure  of  the  cervix  and  then  well  away  from  the  vaginal  edge.  The  three 
sutures  are  passed  through  the  vaginal  mucosa  at  such  distances  from  each  other  as  to  take  up  a 
certain  amount  of  surplus  between  them  when  tied. 


VAGINO-nXATION    FOR    DESCENSUS    UTERI 


193 


II 


Fig.  61. — .\fter  the  three  posterior  sutures  are  tied  two  cervico-vaginal  sutures  are  passed 
on  either  side,  at  the  antero-lateral  area  of  the  circumference  of  the  cervix.  These  when  tied  bring 
the  edges  of  the  lower  end  of  the  longitudinal  incision  in  the  anterior  wall  fairly  close  together. 


13 


VAGINO-FIXATION    FOR    DESCENSUS    UTERI 


195 


Fig.  62. — After  tying  the  posterior  and  the  antero-lateral  sutures  the  lateral  area  of  the  cervix 
still  remains  to  be  covered  by  the  vaginal  mucosa.  This  may  be  done  as  on  the  left  side  of  the 
drawing  by  passing  cervico-vaginal  sutures  and  thus  covering  the  cervix  by  pleated  mucosa,  or  as  is 
done  on  the  right  side  of  drawing,  by  passing  one  suture  through  the  vaginal  mucosa,  then  through 
the  cervix  and  out  of  the  cervical  canal,  then  back  through  the  cervical  canal  and  the  cervical  tissue 
and  finally  through  the  vaginal  mucosa.  This  is  to  be  followed  by  several  up  and  down  sutures 
through  the  vaginal  mucosa  alone,  as  shown  by  the  one  external  suture  on  the  right  side. 


VAGINO-FIXATIOxN    FOR    DESCENSUS    UTERI  197 

cases  where  the  anterior  vaginal  wall  is  congenitally  a  short  one,  in 
wliich  cases  vaginal  fixation  is  contra-indicated. 

If  in  the  above-mentioned  class  of  cases  of  retroversion  or  retro- 
llexion  complicated  by  elongatio  colli,  by  cystocele,  by  descent  of  the 
uterus,  etc.,  the  simple  operation  of  vaginal  fixation  is  done  the  opera- 
tion fails  of  its  best  results  as  can  be  seen  from  figures  54  and  55. 

Figure  54  shows  the  fixation  sutures  which  are  to  unite  the  anterior 
wall  of  the  uterus  to  the  anterior  vaginal  wall  in  the  simple  operation 
of  vaginal  fixation. 

Figure  55  shows  the  sutures  tied  and  the  longitudinal  and  trans- 
verse incisions  in  the  act  of  being  closed  by  running  catgut  suture. 

Figures  54  and  55  show  in  an  exaggerated  form  the  lack  of  taut- 
ness  in  the  anterior  vaginal  wall  in  the  case  of  simple  vaginal  fixation 
done  for  cystocele  with  descent.  The  important  point  to  be  noted, 
however,  is  the  faulty  position  of  the  cervix.  (The  cervix  and  uterus 
are  shown  for  purposes  of  demonstration  much  further  out  beyond 
the  vulva  than  is  actually  the  case.)  This  demonstrates  that  the 
lack  of  tautness  in  the  anterior  vaginal  wall  is  not  alone  responsible 
for  the  position  which  the  cervix  has  assumed.  The  trouble  is  that 
the  uterus  in  its  new  position  is  too  long,  hence  the  simple  opera- 
tion does  not  throw  the  cervix  high  up  and  far  back  when,  as  is  depicted 
in  this  drawing,  we  are  dealing  with  an  enlarged  or  elongated  uterus, 
a  uterus  which  has  descended.  It  is  necessary  to  overcome  this  obstacle 
when  dealing  with  ptoses  of  the  uterus  w^hen  the  uterus  is  enlarged 
and  elongated,  when  there  is  an  elongation  colli,  or  when  there  is 
a  cystocele  with  descent  of  the  uterus,  and  most  certainly  is  it  necessary 
in  the  major  degrees  of  ptosis  and  in  the  case  of  total  prolapse  of 
the  uterus.  To  overcome  this  obstacle  it  is  necessary  (i)  to  perform 
a  high  amputation  of  the  cervix  at  the  level  of  the  internal  os.  (2) 
It  is  necessary  to  make  a  taut  anterior  vaginal  wall  to  which  the  fundus 
is  to  be  fixed.  While  this  tautness  may  be  produced  without  resection 
of  any  part  of  the  flaps,  it  is  often  advisable  to  resect  an  oval  or  a 


198  VAGINAL   CELIOTOMY 

triangular  area  from  each  of  the  two  flaps  produced  in  the  anterior 
vaginal  wall  after  separation  of  the  bladder.  This  tautness  may 
be  produced  by  either  one  of  two  methods  of  attaching  the  vaginal 
mucosa  to  the  new  cervix  opening  after  an  amputation  of  the  cervix 
has  been  done. 

The  accompanying  illustrations  show  the  two  methods  of  accom- 
plishing these  steps.  In  any  case  of  simple  vaginal  fixation  sutures 
are  passed  through  the  edges  of  the  flaps  and  through  the  anterior 
wall  of  the  uterus.  The  following  drawings,  Figs.  56-62  inclusive, 
show  the  amputation  of  the  cervix  without  resection  of  any  part  of 
the  anterior  vaginal  flaps;  and  the  drawings.  Figs.  63-64,  show  the 
same  operation  completed  by  resection  of  a  large  portion  of  the 
anterior  vaginal  flaps.  After  the  uterus  has  been  replaced  within 
the  peritoneal  cavity,  and  after  four  fixation  sutures  have  been  passed 
through  the  vaginal  flaps  and  through  the  uterine  wall,  the  cervix, 
grasped  with  a  volsellum  forceps,  is  pulled  down  toward  the  vulva. 
A  transverse  incision  is  made  through  the  posterior  wall  of  the  cervix, 
and  the  upper  hp  of  the  incision  is  grasped  with  two  long  artery  forceps 
as  shown  in  figure  56.  The  finger  covered  with  gauze  dissects  the 
lower  lip  of  the  incision  away  from  the  posterior  wall  of  the  cervix 
up  to  and  beyond  the  peritoneal  fold  of  Douglas  (Fig.  57).  The 
cervix  is  then  pulled  out  and  to  one  side ;  a  snip  with  a  pair  of  scissors 
cuts  through  the  vaginal  mucosa  on  the  lateral  wall  of  the  cervix 
which  still  remains  as  a  bridge  separating  the  transverse  incision 
on  the  anterior  cervix  wall  from  the  transverse  incision  on  the  posterior 
cervix  wall,  and  the  index  finger  or  the  thumb,  covered  with  gauze, 
pushes  up  this  vaginal  mucosa  and  separates  it  from  the  cervix  up  to 
the  situation  of  the  uterine  arteries,  as  is  shown  in  figure  58. 

Figure  59  shows  the  amputation  of  the  cervix  carried  on  at  the 
level  of  the  internal  os.  The  cervical  canal  is  then  dilated,  after  the 
anterior  lip  has  been  grasped  by  a  volsellum  forceps,  and  the  vaginal 
mucosa  is  then  united  about  the  internal  os.     Chromic  catgut  sutures 


VAGINO-FIXATION    FOR    DESCENSUS    UTERI 


199 


Fig.  63. — Instead  of  passing  the  cervix  sutures  as  depicted  in  figures  60,  61,  and  62,  the 
cervico-vaginal  sutures  are  passed  first  through  the  posterior  wall  of  cervix  and  then  out  from 
these  in  direct  continuity  on  either  side,  passing  thus  toward  the  anterior  wall  of  the  cervix  and 
taking  up  the  slack  in  the  posterior  and  lateral  fornices.  Thus  two  very  large  anterior  vaginal 
Haps  result.  These  when  resected  to  the  desired  extent  furnish  a  taut  anterior  vaginal  wall.  In 
the  early  part  of  the  operation  four  fixation  sutures  have  been  passed  through  the  anterior  wall 
of  the  uterus  only,  and  have  been  grasped  with  artery  forceps.  These  are  to  be  threaded  and 
passed  through  the  edges  of  the  uterine  vaginal  flaps  later  on  after  the  cervix  has  been 
thoroughly  covered,  and  after  the  esxcess  of  the  vaginal  flaps  has  been  resected. 


VAGINO-FIXATION    FOR    DESCENSUS    UTERI 


20I 


Fig.  64. — The  two  anterior  vaginal  flaps  resulting  from  the  method  depicted  in  figure  63 
may  be  resected  in  any  desired  form  Oval,  small  or  large  triangular  areas  may  be  resected 
after  which  the  sutures  which  have  been  passed  through  the  anterior  wall  of  the  uterus  in  the 
early  part  of  the  operation  are  threaded  and  passed  through  the  edges  of  the  vaginal  flaps. 


VAGINO-FIXATION    FOK    DESCENSUS    UTERI  203 

Nos.  3  and  4  are  passed  through  the  cervical  canal,  through  the  entire 
wall  of  the  cervix,  and  out  through  the  vaginal  mucosa.  The  first 
three  are  passed  as  show^n  in  figure  60  and  then  are  tied.  The  succeed- 
ing sutures  are  passed,  two  on  either  side,  as  shown  in  figure  61. 
These  are  passed  in  such  a  manner  that  they  bring  the  two  edges 
of  the  longitudinal  incision  almost  into  apposition  when  tied  as  shown 
in  figure  62.  The  remaining  area  of  the  lateral  walls  of  the  cervix 
may  then  be  closed  or  covered  in  either  of  two  ways:  either  by  pass- 
ing sutures  as  shown  on  the  left-hand  side  of  figure  62  through  the 
cervix  and  out  through  the  lateral  vaginal  mucosa  just  as  the  other 
cervico- vaginal  sutures  were  applied,  or,  as  shown  on  the  right-hand 
side  of  the  drawing,  through  the  vaginal  mucosa,  then  out  through 
the  cervical  canal,  then  back  through  the  cervical  canal  and  out  through 
the  vaginal  mucosa,  the  next  suture  to  that  being  passed  either  in 
the  same  way  or  simply  straight  up  and  down  through  the  vaginal 
mucosa  (Fig.  62).  In  this  way  the  entire  cervix  is  covered  by  vaginal 
mucosa  after  which  the  four  utero-vaginal  fixation  sutures  are  tied. 

If  this  operation  is  performed  in  the  case  of  cystocele  or  descent 
of  the  uterus  with  lax  anterior  vaginal  w^all,  a  condition  shown  in 
figure  62,  the  disadvantage  resulting  from  the  failure  to  resect  parts 
of  the  anterior  vaginal  flaps  is  evident.  The  method  which  best 
overcomes  this  disadvantage  is  the  following: 

Fixation  sutures  are  passed  through  the  anterior  wall  of  the  uterus 
but  are  not  passed  through  the  vaginal  flaps  as  was  done  in  figure 
54,  but  are  simply  allowed  to  pass  out  through  the  vagina  and  are 
to  be  held  by  artery  forceps  for  subsequent  use.  The  attaching  of 
the  vaginal  mucosa  to  the  cervix  is  begun  as  in  figure  61,  by  three 
sutures  which  are  tied,  but  the  subsequent  sutures  take  up  the  lateral 
borders  of  the  vaginal  mucosa  closely,  allowing  of  no  such  reefs 
as  are  evident  in  figure  62.  As  a  result  of  this  procedure  all 
the  surplus  vaginal  mucosa  in  the  fornix  is  left  as  two  redundant 
flaps  shown  in  figure  63.     /\ny  desired  part  of  these  flaps  is  then 


204  VAGINAL    CELIOTOMY 

resected  from  the  redundant  tissue  shown  in  figure  64,  after  which 
the  four  fixation  sutures  which  have  already  been  passed  through 
the  anterior  wall  of  the  uterus  are  then  threaded  in  a  needle  in  turn 
and  passed  through  the  edges  of  the  anterior  vaginal  flaps  to  com- 
plete the  vaginal  fixation.  As  a  result  of  these,  two  important  steps 
the  anterior  uterine  wall  is  attached  in  a  manner  which  lifts  the  uterus 
up  and  holds  it  in  a  more  elevated  and  nearly  horizontal  position, 
and  the  hypertrophied,  often  elongated  cervix  has  been  amputated. 
These  procedures  allow  the  lower  end  of  the  uterus  to  be  thrown 
high  up  and  far  back.  This  method  of  attaching  the  vaginal  mucosa 
around  the  internal  os  takes  away  much  of  the  enlarged  calibre  of 
the  upper  vagina,  a  condition  so  often  present  with  descent  of  the 
uterus  and  due  to  the  existence  of  a  large  relaxed  fornix  and  of  posterior 
enterocele.  The  advantage  gained  by  the  removal  of  this  condition 
in  the  upper  vagina  can  be  fully  appreciated,  however,  only  when 
the  subject  of  total  prolapse  of  the  uterus  is  considered. 


TOTAL  PROLAPSE  OF  THE  UTERUS. 

Slight  ptosis  of  the  uterus  may  occur  with  the  fundus  in  anteflexion 
or  anteversion,  but  marked  ptosis  of  the  uterus  imphes  an  associated 
retrodeviation.  Neither  can  the  uterus  leave  the  pelvis  or  vagina  if ' 
situated  in  physiologic  anteflexion.  It  must  first  come  into  a  position 
in  which  its  axis  has  almost  the  same  direction  as  that  of  the  vagina. 
A  retroversion  or  slight  retroflexion  then  permits  abdominal  pressure, 
among  other  accessory  factors,  to  cause  a  ptosis  of  severe  degree. 

If  a  severe  degree  of  ptosis  carries  the  uterus  down  no  further 
than  to  the  vulva,  such  an  hysteroptosis  may  be  defined  by  the  term 
descensus  uteri.  If  the  uterus  descends  beyond  the  vulva,  the  con- 
dition is  called  a  prolapse.  Only  a  small  propoxtion  of  retroversions 
end  in  marked  ptosis  or  in  descensus  or  in  prolapse.  These  do  not 
occur  if  there  are  no  lengthened  ligaments,  if  the  broad  ligaments 
are  elastic  or  sclerosed,  if  the  utero-sacral  ligaments  are  short,  if  there 
is  no  tugging  by  a  loosened  vagina,  if  there  is  no  atrophy  of  the  peri- 
vaginal tissue,  if  there  is  no  injury  to  the  levator  ani  muscles,  etc. 

With  marked  ptosis  of  the  uterus  there  is  descensus  vaginae.  The 
anterior  w^aU  of  the  upper  vagina  and  the  posterior  wall  of  the  upper 
vagina  are  descended  in  association  with  any  marked  descent  of  the 
uterus.  The  nearer  the  portio  approaches  the  \nalva,  the  more  is 
the  vaginal  canal  shortened,  until  in  the  more  extreme  cases  the  latter  also 
finally  lies  outside  the  vulva.  This  secondary  involvement  of  the 
anterior  vaginal  wall  must  be  distinguished  from  true  cystocele. 
The  term  cystocele  seems  to  be  applied  to  any  protrusion  of  the  mucous 
membrane  of  the  anterior  vaginal  wall  which  is  externally  visible, 
or  which  actually  extends  beyond  the  external  genitaha.  True  cysto- 
cele is  really  a  hernia  of  the  bladder  through  the  lower  half  of  the 

205 


2o6  VAGINAL   CELIOTOMY 

anterior  vaginal  wall,  which  occurs  without  marked  ptosis  of  the 
uterus. 

Complete  prolapse  of  the  uterus  necessarily  rolls  the  vagina  out. 
However,  descent  of  the  lower  vaginal  walls  may  occur  primarily, 
or  simultaneously  with  marked  ptosis  of  the  uterus.  Descensus 
uteri  and  this  true  prolapse  of  the  vagina  are  due  to  the  same  causes, 
but  each  may  have  an  influence  on  the  other,  and  they  are  then  two 
interdependent  affections. 

There  persists,  especially  after  several  or  instrumental  labors, 
an  elongation  of  the  round  ligaments  and  of  the  six  consecutive  tissue 
ligaments  associated  with  the  uterus  and,  more  especially,  the  liga- 
menta  cardinaha.  There  is  deepening  and  sinking  of  the  peritoneal 
pelvic  recesses  anterior,  and  especially  posterior,  to  the  uterus.  Since 
the  normal  anteverted  or  anteflexed  position  of  the  uterine  fundus 
is  maintained  only  if  the  cervix  is  high  up  and  far  back,  such  descent 
of  the  cervix  and  fornices  permits  the  fundus  to  drop  back  into  retro- 
version unless  there  be  present  unusually  short  and  muscular  round 
ligaments. 

Injury  to  the  anterior  and  posterior  attachments  of  the  levator  ani 
muscles  has  the  greatest  bearing  on  this  question.  Injury  to  the 
anterior  fibers  may  aid  in  the  development  of  cystocele.  Injury  to 
the  posterior  fibers  of  these  muscles,  even  when  the  perineum  is  not 
torn,  results  in  a  very  flabby  vulvar  outlet,  and  when  the  perineum  is 
torn,  in  a  hernia  of  the  rectum  (rectocele).  Many  cases  do  not  result 
in  more  than  uterine  ptosis,  or  retroversion,  or  retroflexion,  even  when 
they  develop  cystocele,  or  both.  Loss  of  the  support  which  the  levator 
ani  furnishes  the  vagina  may  be  of  importance.  In  many  cases  the 
uterus  is  elongated,  much  enlarged,  the  cervix  is  thickened  and  hyper- 
trophic and  the  vaginal  mucosa  very  thick.  There  is  subinvolution,  and 
at  times  atrophy  of  the  elastic  periuterine  and  perivaginal  tissues. 
There  is  not  infrequently  associated  with  this  condition  (even  where 
labors  have  not  been  numerous   or  instrumental)  a  state  of  general 


TOTAL    PKOLAPSI':    OF    THE    UTERUS  207 

inelasticity  associated  with  flabby  subinxcjlutcd  abdominal  walls  and 
with  varying  degrees  of  gastroptosis  and  enteroptosis.  What  effect 
may  persistence  of  retroversion  and  descent  associated  with  intra- 
abdominal pressure  and  accessory  pressure  have  in  such  cases?  It 
leads  to  further  uterine  descent,  and  then,  if  we  have  perivaginal  atrophy, 
large  vagina,  thickened  mucosa,  we  observe  further  vaginal  descent:  (i) 
pushed  down  by  uterus;  (2)  pulling  uterus  down;  or  (3)  occurring 
simultaneously  with  uterine  descent,  but  primarily  independent  of  it. 

The  vagina,  except  at  its  outer  end,  is  simply  surrounded  by  connect- 
ive tissue.  The  only  thing  which  prevents  the  vagina  from  being 
pushed  down  by  abdominal  pressure  is  the  action  of  the  levator  ani 
muscles  and  the  character  of  the  connection  of  the  vagina  with  the 
surrounding  connective  tissues.  The  levatores  ani  and  constrictor 
cunni  are  decidedly  stretched  and  often  torn,  and  as  a  result  the  narrow 
vagina  is  widened  and  the  original  narrow  slit  becomes  a  large  canal. 
Atrophy  or  degeneration  of  certain  tissues  about  the  vagina  may  cause 
the  mucous  membrane  to  lie  in  folds,  as  is  so  frequently  the  case  at  the 
climacterium,  when  there  is  a  resorption  of  fat  and  a  change  of  the  con- 
nective tissue,  a  disappearance  of  active  elastic  fibers,  and  a  loosening 
of  the  various  relations.  (Such  changes  not  infrequently  occur  also 
in  younger  women). 

The  pathological  factors  may  be  grouped  as  follows: 

1.  Tendency  to  inelasticity. 

2.  Labor  injuries,  especially  if  repeated. 

3.  Subinvolution;  ligaments,  uterus,  vagina,  etc. 

4.  Primary  ptosis  leading  to  retroversion.  Since  retroversion  is 
present,  attention  has  been  paid  to  the  retrodeviation,  and  while  this  is 
an  important  pathological  factor,  the  elements  of  subinvolution,  injury 
to  the  various  muscles,  atrophy  and  predisposition  are  overlooked. 

5.  Posterior  enterocele  and  large  descended  fornix. 

6.  Large  vagina. 

7.  Vagina  loosened,  giving  no  support. 


2o8  VAGINAL    CELIOTOMY 

8.  Loosened  vagina,  actively  tugging  upon  the  uterus. 

9.  Bladder  torn  from  its  fastenings. 

10.  Splanchnoptosis  and  intra-abdominal  pressure. 

11.  Vocation 

12.  Age.  INIost  of  the  extreme  cases  after  the  menopause  age, 
when  there  is  great  atrophy  of  the  elastic  fibers. 

Primary  descensus  and  prolapsus  uteri  are  due  to  inelasticity  and 
stretching  of  the  ligaments  connected  with  the  uterus,  especially  the 
ligaments  cardinalia,  and  to  inelasticity  of  the  pelvic  connective  tissue. 
A  good  perineum  and  a  good  vagina  often  keep  the  uterus  from  coming 
down  too  far  for  varying  periods  of  time.  Often,  too,  the  vagina  does 
not  so  much  pull  the  uterus  down  as  it  fails  to  keep  it  up.  Loose 
vagina,  on  the  other  hand,  may  in  some  cases  eventually  pull  the  uterus 
down,  unless  all  things  are  favorable,  such  as  good  broad  Hgaments,  or 
sclerosed  broad  ligaments  and  utero-sacral  ligaments.  For  such  second- 
ary descensus,  then,  the  soil  must  be  ready,  even  though  it  is  due  in  a 
great  measure  to  the  action  of  the  prolapsing  vagina  on  the  uterus. 

The  variations  from  the  normal  are  indicated  by  the  following  types : 
(i)  ptosis  alone;  (2)  cystocele  alone;  (3)  ptosis  and  cystocele;  (4) 
ptosis,  retroversion,  with  or  without  cystocele;  (5)  descensus  to  vulva; 
(6)  descensus  with  hypertrophied  cervix  and  thickened  mucosa;  (7) 
prolapsus  outside  of  the  vulva;  (8)  prolapsus  with  elongatio  colli 
and  hypertrophy;  (9)  prolapsus  with  vagina  pushed  down;  (10)  pro- 
lapsus with  vagina  pulling  down;  (11)  prolapsus  with  complete  peeling 
off  of  the  posterior  vaginal  wall. 

In  the  most  extreme  cases  all  union  of  the  vag^inal  canal  with  sur- 
rounding  and  connective  and  elastic  tissues  has  been  dissolved;  all 
relations  of  fornices  to  normally  situated  peritoneal  or  uterosacral 
structures  has  been  altered ;  all  attachment  of  the  uterus  to  fixed  points 
of  the  pelvic  wall  has  ended  in  tremendous  elongation  or  atrophy. 

Surgically,  therefore,  we  have  to  take  into  consideration  the  follow- 
ing points,  which  are: 


TOTAL    PROLAPSE    OF    THE    UTERUS  209 

1.  Bladder  and  anterior  vaginal  wall. 

2.  Retrodeviation. 

3.  Elongated  uterus,  hypertrophied  cervix. 

4.  Roof  of  vagina,  which  sliould  l^e  restored  to  its  former  elevation. 

5.  Posterior  enterocele. 

6.  Capacious  vagina,  descended  vagina.     Injury  to  levatores  ani. 

7.  Rectocele  and  perineum. 

1.  We  must  correct  the  descent  of  the  bladder  which  has  come 
down  together  with  the  anterior  vaginal  wall  or  which  constitutes  a 
hernia  of  the  bladder  through  the  anterior  w^all.  On  thorough  separa- 
tion of  the  bladder  to  loosen  it  from  all  union,  the  bladder  shrinks  and 
this  method  of  dissection  furnishes  thick  flaps  of  vaginal  mucosa  and 
submucosa.  For  cystocele  alone  we  may,  then,  do  a  resection  of  flaps 
and  an  anterior  colporrhaphy  and  stop. 

2.  We  must  place  the  uterus  in  such  a  position  that  future  retrode- 
viation is  avoided  and  subsequent  descent  prevented.  By  entering  the 
peritoneal  cavity  we  take  out  the  uterus,  fasten  it  to  the  anterior  vaginal 
wall  after  resecting  part  of  the  anterior  vaginal  wall.  The  bladder 
thus  rests  on  the  uterus  and  if  the  utero-vaginal  union  is  a  firm  one  the 
bladder  can  never  descend.  This  fixation  of  the  uterus  does  not  elevate 
the  fundus  above  the  normal,  but  puts  it  behind  the  symphysis.  (Ven- 
trofixation demands  good  abdominal  walls,  firm  union  on  the  part  of  the 
uterus,  and  then  the  uterus  has  to  bear  the  great  tugging  force  from 
below,  and  no  certainty  of  permanent  correction  of  the  cystocele 
results.) 

3.  As  a  rule,  now,  the  cervix  of  the  vagino-fixed  uterus  is  acutely 
flexed,  having  a  tendency  to  project  down  toward  the  \Tilva,  showing 
that  fixation  of  the  uterus  fundus  does  not  shift  the  elongated  and 
hypertrophied  cervix  up  and  back  as  we  might  wish.  Therefore  a 
high  amputation  of  the  useless  cervix  is  done  to  permit  the  uterus  to 
assume  a  more  horizontal  position. 

4.  The  fornix  or  roof  is  thus  placed  at  an  elevation  approximating 
14 


2IO  VAGINAL   CELIOTOMY 

the  normal.  The  lower  end  of  the  uterus  is  by  this  method  thrown 
upward  after  a  high  amputation,  the  uterus  then  lying  more  horizontally, 
even  more  so  than  normally.  Although  the  fundus  is  not  ele- 
vated (i.e.,  toward  the  abdomen),  yet  its  position  is  well  fixed  and  the 
area  of  the  new  external  os  is  elevated  and  thrown  back.  The  simple 
method  of  amputation  is  of  itself  sufficient  to  shift  and  lift  the  fornix 
upward  only  if  the  vaginal  walls  are  not  loosened,  if  the  cervix  is  not 
large,  if  the  vagina  is  not  large,  and  if  the  upper  posterior  vaginal  wall 
is  not  prolapsed. 

5.  We  now  do  away  with  the  posterior  enterocele,  which  is  as  much 
a  hernia  in  the  posterior  fornix  as  is  the  cystocele  in  the  anterior.  With 
large  cervix  and  prolapse  of  the  upper  posterior  vaginal  wall,  we  must 
sew  the  vaginal  mucosa  about  the  cervix  in  such  a  manner  as  to  do 
away  with  the  surplus  fornix  tissue.  This  ends  in  the  removal  of  two 
vaginal  flaps,  which  narrows  the  upper  vagina  very  much.  This  step 
and  the  resection  of  the  posterior  vaginal  wall  overcome  the  posterior 
enterocele. 

6.  We  make  the  vagina  of  small  calibre,  constituting  a  canal  whose 
walls  are  fixed.  We  must  narrow  the  entire  lumen  of  the  vagina  by 
resection  of  the  posterior  vaginal  wall  and  union  of  levatores  ani. 

7.  We  now  correct  the  rectocele  and  repair  the  perineum  and  the 
relaxed  pelvic  outlet  by  a  high  colpoperineorrhaphy — an  essential  point 
is  the  sewing  of  the  separated  levatores  ani  across  and  in  front  of  the 
denuded  rectocele.  By  beginning  the  denudation  from  below  in  the 
performance  of  this  step,  we  get  a  very  thick  vaginal  wall  down  to  the 
mucosa,  and  then  extend  the  separation  of  the  posterior  vaginal  wall  up 
to  the  cervix  in  order  to  carry  out  step  6. 

In  the  extreme  type  of  total  prolapse  with  great  hypertrophy  of 
the  cervix  (Fig.  65)  the  following  method  is  to  be  practised: 

Taking  firm  hold  of  the  vaginal  portion  of  the  cervix  a  transverse 
incision  is  made  with  the  scissors.  The  upper  margin  of  the  incision 
is  grasped  by  two  forceps  and  lifted  up.     With  the  preliminary  aid 


TOTAI-    FROl.APSK    OF    THE    UTERUS 


211 


Fig.  65. — Drawing  of  typical  form  of  old  complete  prolapse  of  the  uterus  with  tremendous 
hypertrophy  of  the  cervix  so  that  the  cervix  is  larger  than  the  fundus.  The  area  around  the 
external  os  often  evidences  large  decubitus  ulcers. 


TOTAL    PROLAPSE    OF    THE    UTERUS 


213 


Fig.  66. — The  anterior  vaginal  wall  has  been  dissected  away  by  the  inverted  J_ -incision. 
The  bladder  has  been  thoroughly  separated  from  the  anterior  wall  of  the  cer\'i.x  and  uterus  so  that 
it  is  retracted  upward.  Beneath  it  the  vesico-uterine  fold  of  the  peritoneum  is  seen,  unopened. 
The  bladder  is  thoroughly  separated  as  well  from  the  upper  areas  of  the  vaginal  flaps. 


TOTAL    PROIwVPSK    OF    THE    UTTCRUS 


215 


Fig.  67. — The  peritoneal  cavity  is  entered  by  a  wide  transverse  incision,  the  peritonea 
fold  being  grasped  by  mouse-toothed  forceps  and  easily  incised.  The  bladder  is  held  completely 
out  of  sight  by  the  anterior  speculum. 


TOTAL    PROLAPSE    OP    THE    UTERUS 


217 


Fig.  68. — The  anterior  speculum  having  been  introduced  through  the  transverse  incision  in 
the  peritoneal  plica,  the  anterior  wall  of  the  uterus  is  grasped  by  successively  applied  volsella, 
the  cervix  is  at  the  same  time  pushed  back  either  by  the  posterior  speculum  or,  better,  by  volsella 
attached  to  the  cervix.  The  fundus  is  readily  drawn  out  through  the  vagina  beyond  the  \'ulva. 
Between  the  posterior  wall  of  the  uterus  and  the  anterior  speculum  is  a  wide  space  through  which 
the  adnexa  are  delivered  and  examined.  If  by  any  chance  the  patient  may  still  conceive,  an  area 
of  each  tube  should  be  resected. 


TOTAL    PROLAPSE    OF    THE    UTERUS 


219 


Fig.  69. — To  prevent  conception  the  mesosalpinx  is  tied  by  two  or  more  mattress  sutures  at 
any  desired  point.  The  tube  is  ligated  at  two  points  three  quarters  of  an  inch  or  more  apart,  and 
the  intervening  area  of  the  tube  is  removed  in  such  a  manner  that  the  exposed  ends  of  the  tubal 
mucosa  may  be  covered  by  fine  catgut  sutures  which  unite  the  two  layers  of  the  mesosalpinx. 


TOTAL    PROLAPSK    OF    THE    UTERUS  221 

of  the  scissors  and  then  of  the  hngers  covered  with  gauze,  the  bladder 
is  dissected  off  from  the  anterior  wall  of  the  cervix  and  the  anterior 
wall  of  the  uterus  up  to  the  vesico-uterine  cul  de  sac.  The  bladder 
is  freed  entirely  from  its  median  and  lateral  union  to  the  cervix  and 
uterus.  The  two  forceps  on  the  upper  edge  of  the  incision  are  now 
pulled  downward,  and  a  pair  of  straight  sharp-pointed  scissors  make 
a  single  snip  between  the  two  forceps.  After  this  little  cut  is  made, 
we  readily  see  the  thickness  of  the  vaginal  wall  and  note  the  plane 
of  separation  between  it  and  the  bladder.  Introducing  the  lower 
blade  of  the  scissors  carefully  in  this  plane,  between  the  vaginal  mucosa 
and  the  bladder,  we  incise,  by  continuous  snips  of  the  scissors,  the 
anterior  vaginal  wall  to  any  desired  distance,  usually  going  to  within 
an  inch  of  the  external  urethra.  That  being  done  (and  the  method 
is  easy  except  where  the  mucosa  is  thin),  the  two  future  flaps  result- 
ing from  this  longitudinal  incision  are  then  everted,  and  turned  inside 
out  by  the  two  pairs  of  forceps.  A  pair  of  scissors  makes  a  few  snips 
at  the  corners  near  the  forceps,  to  loosen  the  attachment  of  the  bladder. 
With  the  finger  covered  with  gauze,  an  important  aid,  the  bladder 
is  peeled  off  from  these  two  anterior  flaps  of  the  vaginal  wall  as  far 
as  one  chooses  to  go  laterally.  The  same  thing  is  done  on  either 
side.  Having  carried  the  separation  of  the  bladder  upward  a  short 
distance,  forceps  are  applied  in  succession  along  the  cut  edges  of  this 
longitudinal  incision,  and  the  bladder  is  thoroughly  separated  from 
all  union  with  its  surrounding  vaginal  structure  (Fig.  66).  Finally, 
the  bladder  is  pushed  out  of  the  way  by  a  retractor  applied  under- 
neath it,  and  what  is  now  disclosed  to  view  is  the  vesico-uterine  fold 
of  peritoneum.  This  is  carefully  pulled  out  and  makes  just  as  distinct 
a  fold  as  does  the  peritoneum  when  doing  an  abdominal  laparotomy. 

Since  we  are  going  to  do  a  vaginal  fixation  we  make  a  transverse 
incision  in  the  peritoneum  (Fig.  67).  It  is  then  easy  to  bring  the 
fundus  into  the  vagina  through  this  peritoneal  incision. 

Pushing  the  anterior  retractor  into  the  peritoneal  cavity,  the  fundus 


222  VAGINAL   CELIOTOMY 

is  brought  out  along  the  under  surface  of  the  retractor,  M^hile  the  cervix 
at  the  same  time  is  being  pushed  back.  When  that  is  done,  in  the 
average  case,  the  fundus  is  clearly  in  view  (Fig.  68).  The  last  apphed 
volsellum  makes  the  fundus  hang  do^vn,  and  we  have  a  space  of  a 
diameter  of  several  inches,  through  which  we  can  do  the  tying  off 
of  the  tubes  (Fig.  69)  or  resection  of  the  ovaries  or  other  operations 
which  are  considered  necessary.  The  length  of  the  longitudinal 
incision  in  the  vaginal  mucosa  shown  in  the  drawing,  figure  66,  deter- 
mines the  size  of  the  space  through  which  we  bring  the  uterus  out. 
The  uterus  must  be  brought  out  in  order  to  have  free  observation 
and  an  unobstructed  field  for  intrapelvic  operations. 

The  complete  separation  of  the  bladder  from  its  attachment  to 
the  cervix,  to  the  anterior  wall  of  the  uterus,  to  the  lateral  margins 
of  the  lower  part  of  the  uterus,  and  to  the  anterior  fornix  and  anterior 
vaginal  wall  permits  the  bladder  to  shrink  up  to  a  very  small  size 
and  permits  of  its  dislocation  into  any  desired  relation  to  the  uterus. 
It  is  therefore  obvious  that  if  the  uterus  is  now  attached  by  its  anterior 
surface  to  the  vaginal  flaps,  so  that  the  fundus  lies  up  behind  the 
symphysis,  the  bladder  must  of  necessity  then  rest  on  the  fundus 
and  posterior  wall  of  the  uterus  and  can  never  again  come  into  con- 
tact with  any  area  of  the  anterior  vaginal  wall.  It  is  desirable,  before 
attaching  the  uterus,  to  resect  such  an  area  of  the  anterior  vaginal 
flaps  as  will  make  a  taut  anterior  vaginal  wall — a  wall  of  such  a  nature 
that  it  neither  permits  the  fundus  to  sag  down  into  the  vagina  nor 
forces  it  too  far  back  from  intimate  relation  with  the  symphysis. 
In  this  position  of  the  uterus  the  bladder  assumes  a  new  and 
permanent  relation  to  the  posterior  uterine  wall.  It  is  not  necessary, 
nor  do  I  deem  it  advisable  except  in  rare  instances,  to  sew  the  perit- 
oneum on  the  posterior  wall  of  the  bladder  to  the  peritoneal  covering 
of  the  posterior  wall  of  the  uterus  at  the  level  of  the  internal  os.  Resec- 
tion of  the  flaps  and  fixation  of  the  uterus  to  the  anterior  vaginal 
wall  may  be  carried  out  at  this  stage,  but  in  most  cases  the  fixation 


Tf)TAL    PROLAPSE    OF    TTIE    UTERUS 


22' 


Fig.  70. — If  the  uterus  is  now  to  be  united  to  the  anterior  flaps  which  have  been  diminished 
in  size  by  any  form  of  resection,  triangular  or  oval,  then  fixation  sutures,  two  of  silk  and  two  of 
chromic  catgut,  are  passed  through  the  edges  of  the  vaginal  flaps  and  through  the  anterior  wall  of 
the  fundus  (Fig.  50).  If  the  attachment  of  the  uterus  to  the  anterior  vaginal  flaps  is  to  be  done 
at  a  later  stage  of  the  operation,  the  four  fixation  sutures  are  simply  passed  through  the  anterior 
wall  of  the  uterus  and  grasped  by  forceps  as  above.  These  are  threaded  and  passed  through 
the  vaginal  flaps  later  on,  as  in  figure  78. 


TOTAL    PKOLAPSE    OF    THE    UTERUS 


225 


Fig.  71. — The  fundus  has  been  replaced  into  the  peritoneal  cavity;  the  cervix  has  been  pulled 
further  out  beyond  the  vulva  and  up  toward  the  urethra,  and  the  dotted  line  shows  the  point  at 
which  the  scissors  make  a  wide  transverse  incision  through  the  posterior  vagina!  mucosa. 


15 


TOTAL    I'RfJi.APSK    OF    THE    UTERUS 


227 


Fig.  72. — The  upper  lip  of  the  vaginal  incision  is  grasped  b}-  one  or  more  forceps  and,  with 
the  aid  of  scissors  and  the  gauze-covered  index  finger,  the  bands  uniting  the  mucosa  to  the 
posterior  wall  of  the  cer\ix  are  dissected  upward  to  the  cul  de  sac  of  Douglas,  and  the  peritoneum 
may  then  be  dissected  and  pushed  further  up  without  entering  the  peritoneal  cavity. 


TOTAI,  PROLAPSE  OF  Till';  UTERUS 


229 


Fig.  73. — The  cer\ix  is  then  pulled  to  one  side  and  the  bridge  of  thick  mucosa  intervening 
between  the  anterior  transverse  incison  in  figure  66  and  the  posterior  incision  of  figure  72  is 
incised  down  to  the  structure  of  the  cer\ix  itself  and  the  gauze-covered  thumb  dissects  this  and  its 
underlying  connective  tissue,  rich  in  blood  supply,  up  away  from  the  cervix  itself  until  the  area  of 
the  internal  os  and  the  uterine  vessels  is  reached. 


TOTAL    PROI.APSI".    OF    TIIK    LTKKUS 


2U 


\xl*. 


Fig.  74. — The  huge  hypertrophied  cervix  is  amputated  at  any  desired  level,  care  being  taken 
not  to  cut  the  uterine  arteries.  It  may  be  necessary  to  keep  the  bladder  away  from  the  field  by  an 
anterior  retractor  So  soon  as  the  cervix  has  been  cut,  a  large  volsellum  should  grasp  the  anterior 
lip.     The  volselhim  is  left  out  of  this  drawing  so  as  not  to  obstruct  the  view. 


TOTAL    PROLAPSE    OF    THE    UTERUS 


oo 


Fig.  75. — Heavy  chromic  sutures  are  passed  through  the  cervical  canal,  through  the  structure 
of  the  cervix,  and  through  the  vaginal  tissue  a  good  distance  from  the  edge  and  are  then  tied  while 
the  vaginal  mucosa  is  brought  up  to  thoroughly  cover  the  exposed  lower  end  of  the  uterus.  While 
this  is  being  done  the  volsellum  should  still  be  in  place  on  the  anterior  lip  of  the  cervix.  After 
a  few  sutures  have  been  tied  this  may  be  removed. 


TOTAL    PROLAPSE    OF    TJJE    UTERUS  235 

of  the  uterus  to  the  resected  flaps  may  be  allowed  to  wait  until  the 
next  two  steps  of  the  operation  have  been  completed,  viz.,  the  amputa- 
tion of  the  cervix  and  the  correction  of  the  posterior  enterocele.  If 
the  uterus  is  now  to  be  fixed  to  the  anterior  vaginal  wall,  I  pass  four 
sutures,  two  of  heavy  braided  white  silk  and  two  of  No.  3  chromic, 
through  the  edges  of  the  anterior  flaps  and  through  the  upper  part 
of  the  uterine  fundus.  If  the  fixation  be  allowed  to  wait,  four 
fixation  sutures  are  carefully  passed  through  the  fundus,  and  their 
ends  are  grasped  by  artery  forceps  (Fig.  70).  These  sutures  are  sub- 
sequently threaded  and  passed  through  the  vaginal  flaps  after  the  next 
two  steps  have  been  carried  out. 

A  high  amputation  of  the  enormously  hypertrophied  cervix  is 
now  in  order.  The  fundus  is  replaced  into  the  pelvic  cavity  with 
or  without  fixation  to  the  flaps  and  the  cervix  is  pulled  down  be- 
yond the  vulva  and  lifted  up  toward  the  urethra  (Fig.  71).  A 
transverse  incision  is  made  through  the  vaginal  mucosa  at  as  high 
a  point  as  possible  without  entering  the  cul  de  sac  of  Douglas;  the 
upper  edge  of  the  incision  is  grasped  with  a  mouse-toothed  forceps 
and  the  index  finger  covered  with  gauze,  sometimes  aided  by  short 
snips  of  blunt-edged  scissors,  separates  the  vaginal  wall  from  the 
posterior  wafl  of  the  cervix  (Fig.  72)  up  to  the  peritoneal  fold  of 
Douglas,  and  continues  to  dissect  this  peritoneal  fold  upward  for  a 
considerable  distance  from  the  posterior  wall  of  the  uterus.  We 
stiU  have  each  lateral  wall  of  the  cervix  covered  by  a  bridge  of  vaginal 
mucosa.  This  bridge  is  incised  with  scissors  down  to  the  actual 
structure  of  the  cervix,  first  on  one  side  and  then  on  the  other,  and 
then  this  lateral  bridge  of  vaginal  mucosa  with  its  submucous  con- 
nective tissue  is  peeled  away  from  the  cervix  by  upward  rubbings 
of  the  gauze-covered  thumb  (Fig.  73).  This  peels  away  from  the 
cervix  smoothly  and  easily  up  to  the  uterine  arteries.  In  this  maneuver, 
as  well  as  in  the  subsequent  dissection  of  the  posterior  vaginal  wall, 
there  is  considerable  oozing,  which  is  of  minor  importance.     Side 


236  VAGINAL   CELIOTOMY 

retractors  are  introduced  then  into  the  vagina  if  necessary,  the  bladder 
is  held  out  of  the  way  by  an  anterior  retractor  if  necessary  and  the 
cervix  is  amputated  at  the  level  of  the  internal  os  by  the  aid  of  scissors 
(Fig.  74).  If  this  amputation  is  carried  on  from  one  side  to  the  other, 
or  from  the  anterior  wall  of  the  cervix  down  through  the  posterior, 
cutting  of  the  uterine  arteries  should  be  avoided.  As  soon  as  the 
canal  of  the  cervix  is  invaded,  the  thick,  anterior  lip  should  be  grasped 
with  single-pointed  volsellum.  After  amputation  of  the  cervix  the 
uniting  of  the  vaginal  mucosa  around  this  new  external  os  is  begun, 
first  at  the  posterior  wall.  No.  3  chromic  catgut  sutures  being  used, 
the  vaginal  mucosa  being  caught  at  least  3/4  of  an  inch  from  the  edge, 
in  order  to  thoroughly  cover  the  denuded  lower  end  of  the  uterus 
(Fig.  75).  Sometimes  the  cervix  which  is  cut  off  is  larger  than 
the  uterus  which  is  left.  When  this  is  done,  in  the  cases  that  are 
not  extremie  as  regards  size  of  uterus  and  cervix,  and  degree  of  pro- 
lapse, etc.,  one  begins  to  unite  the  edges  of  the  dissected  wall  around 
the  cervix,  as  is  done  in  a  simple  typical  high  amputation.  The 
sutures  are  passed  through  the  cervical  canal  and  through  the  structure 
of  the  cervix,  and  the  vaginal  mucosa  is  thus  fastened  all  the  way 
round,  until  finally  we  have  a  new  covering  around  the  cervical  canal 
held  by  three  sutures  behind,  the  same  in  front,  and  several  laterally, 
with  the  formation  of  a  nice  artificial  os. 

The  method  of  sewing  after  high  amputation  of  the  cervix  must 
meet  with  modification  when  the  prolapse  is  extreme. 

After  the  first  suture  is  applied  and  tied,  the  others  are  applied 
close  to  this  one,  first  on  one  side  and  then  on  the  other,  care  being 
taken  to  take  up  the  vaginal  mucosa  snugly,  so  as  to  allow  of  no  reefs 
or  folds.  In  the  same  manner  sutures  are  then  applied  to  the  lateral 
wall  and  then  to  the  antero-lateral  walls  of  the  cervix.  In  this  way 
the  surplus  of  the  posterior  fornix  and  of  the  two  lateral  fornices  is 
done  away  with  (Fig.  76). 

A  large  surplus  of  vaginal  flaps  is  now  noted,   which   consist  of 


TOTAL    l>ROLArSK    OF    Til  K    UTERUS 


237 


Fig.  76. — The  cervix  is  covered  in  continuity  by  the  vaginal  mucosa,  sutures  being  applied 
in  succession  on  either  side  of  the  first  three,  all  the  slack  in  the  posterior  and  lateral  fornices  being 
taken  up,  so  that  the  surplus  of  the  vaginal  mucosa  seen  in  figure  75  results  in  the  production 
anteriorly  of  two  unusually  extensive  flaps  of  mucosa. 


TOTAL  PROLAPSE  OF  THE  UTERUS 


239 


Fig.  77. — Each  flap  is  then  drawn  over  to  the  opposite  side  and  is  resected  to  any  desired 
extent,  oval  or  semicircular  or  triangular  areas  being  removed. 


TOTy\i:    PROLAPSE    OF    THE    UTERUS 


241 


Fig.  78. — After  resection  of  any  desired  area  of  the  anterior  vaginal  flaps  the  sutures  passed  in 
figure  70  are  threaded  and  passed  through  the  edge  of  the  remaining  anterior  flaps.  Sutures 
may  be  tied  at  this  stage  and  the  edges  of  the  flaps  be  further  brought  together  by  running  catgut 
suture,  or  the  tying  of  these  four  fixation  sutures  may  be  left  until  the  posterior  vaginal  wall  has 
been  thoroughly  dissected  and  removed. 


16 


TOTAL    PROL/VPSr:    OK    'I'lIK    UTKRUS 


243 


Fig.  79. — A  pair  of  short  curved  scissors  cuts  a  ribbon  from  the  vagino-perineal  junction, 
running  from  one  volsellum  to  the  other  throughout  the  whole  extent  of  the  exceedingly  loose  and 
flabby  outlet. 


TOTAL    l'R()Ly\PSl';    OF    TJIK    UTKRUS 


245 


Fig.  80. — Three  long  artery  forceps  are  applied  to  the  lower  margin  of  the  resulting  denuded 
area  and  by  their  weight  separate  the  whole  area  to  the  extent  of  one-half  inch.  A  pair  of  mouse- 
toothed  forceps  grasp  the  upper  margin  of  the  denudation  and  a  sharp  knife  begins  the  dissection 
of  the  vaginal  mucosa. 


TOTAL    PROLAPSE    OF    THE    UTERUS 


247 


Fig.  81. — Three  artery  forceps  are  then  applied  to  the  upper  margin  of  the  incision;  that  is, 
to  the  lower  edge  of  the  upper  flap.  The  upper  flap  is  lifted  up,  the  fingers  held  in  such  a  manner 
that  they  support  the  vaginal  flap.  Upward  dissection  is  continued  with  a  sharp  knife  and  then 
with  the  index  finger  covered  with  gauze,  occasionally  aided  by  snips  \\-ith  short  blunt  scissors. 


TOTAL    PROLyVPSE    OF    THE    UTERUS  249 

the  originally  dissected  anterior  vaginal  flaps  plus  the  surplus  gained 
from  the  posterior  and  lateral  fornices.  The  flaps  are  drawn,  first 
one  and  then  the  other,  over  to  the  opposite  side,  and  a  very  large 
triangular  area  is  cut  away  (Fig.  77).  Now  the  uterus  may  be  attached 
to  the  remaining  vaginal  flaps,  each  of  the  four  fixation  sutures  which 
have  been  applied  in  the  uterine  fundus  being  threaded  separately 
and  carried  through  the  vaginal  flaps  near  their  upper  end  (Fig.  78). 
These  may  now  be  tied,  bringing  the  fundus  into  intimate  relation 
with  the  newly  formed  anterior  vaginal  wall  and  the  flaps  below 
these  fixation  sutures  are  then  united  by  interrupted  sutures  of  No. 
3  chromic,  which  pass  through  the  anterior  uterine  wall  at  the  same 
time,  or  else  the  tying  of  these  four  fixation  sutures  may  be  left  until 
the  complete  dissection  of  the  rectum  from  the  posterior  vaginal 
wall  has  been  completed,  for,  if  in  some  instances  these  fixation  sutures 
are  tied  first,  it  is  a  more  difficult  procedure  to  carry  out  a  thorough 
dissection  and  resection  of  the  posterior  vaginal  wall. 

The  next  step  of  the  operation  consists  of  a  high  colpoperineor- 
rhaphy,  which  includes  an  absolute  separation  of  the  rectocele  from 
the  posterior  vaginal  wall  to  within  1/2  to  3/4  of  an  inch  of  the  newly 
formed  external  os,  this  procedure  being  begun  from  below. 

Two  single-bladed  volsella  are  attached  to  the  lateral  margins 
of  the  vulva  at  a  point  which  is  to  constitute  the  lower  end  of  the  new 
posterior  vaginal  wall  and  the  highest  point  of  the  new  perineum. 
These  are  drawn  apart  (before  this  introduce  an  intrauterine  strip 
of  gauze),  and  a  pair  of  curved  scissors  cuts  a  wide,  tape-like  strip 
from  one  volsellum  to  the  other  along  the  lower  edge  of  the  exposed 
vagino-perineal  junction  (Fig.  79).  Three  or  more  heavy  artery 
forceps  are  applied  to  the  skin  edge  after  this  strip  has  been  cut  away 
and  are  allowed  to  hang  down,  so  that  by  their  weight  a  half-inch 
wide  denuded  area  is  apparent.  The  upper  edge  of  this  denuded 
area  is  picked  up  with  a  mouse-toothed  forceps,  and  a  sharp  knife 
begins  the  dissection  of  this  thick  posterior  vaginal  wall  from  the 


250  VAGINAL   CELIOTOMY 

underlying  readily  bleeding  connective  tissue  (Fig.  80).  After  this 
dissection  has  been  well  started  from  one  volsellum  to  the  other, 
three  or  more  artery  forceps  are  applied  to  this  upper  flap.  The 
forceps  are  grasped  in  the  left  hand  and  the  fingers  are  placed  behind 
the  flap  and  the  separation  is  continued  with  the  knife  from  the  under- 
lying tissue  and  then  continued  by  the  index  finger  covered  with 
gauze  (Fig.  81).  After  the  prehminary  dissection  with  the  knife  has 
been  well  started  the  separation  goes  on  easily,  occasionally  aided 
with  the  knife  or  with  blunt-pointed  scissors,  the  operator  being 
extremely  careful  to  avoid  cutting  into  the  rectocele. 

Oozing  is  fairly  brisk,  but  no  attempt  to  check  it  with  artery 
forceps  need  be  made.  The  dissection  should  extend  very  far  laterally, 
especially  so  into  the  lateral  sulci  in  which  rest  the  separated  levator  ani 
muscles.  After  the  flap  has  been  thus  separated  upward  for  a  dis- 
tance of  2  inches,  it  is  pulled  down  taut  and  then  bisected  along  the 
median  line  as  far  as  the  separation  has  been  carried  (Fig.  82).  Artery 
forceps  are  then  apphed  to  the  highest  points  of  these  flap  edges  and 
the  separation  from  the  rectum  upward  and  laterally  is  continued 
(Fig.  83).  As  the  separation  extends  higher  the  flaps  are  bisected  in 
continuity  and  artery  forceps  are  applied  higher  up  in  succession.  In  this 
manner,  the  entire  posterior  vaginal  wall  is  separated  to  within  1/2 
inch  of  its  upper  limit  and  very  well  into  the  lateral  sulci  of  the  vagina 
(Fig.  84).  The  flaps  are  then  drawn  down,  first  on  one  side  and  then 
on  the  other  (Fig.  85) ;  a  large  area  is  resected,  beginning  at  each  vol- 
sellum and  extending  upward  to  the  highest  point  of  the  dissected 
flaps  (Fig.  86).  If  the  uterine  fixation  sutures  have  not  yet  been  tied, 
they  are  tied  now,  and  the  union  of  the  edges  of  what  now  remains  of 
the  posterior  vaginal  flaps  is  begun,  with  heavy  chromic  catgut,  begin- 
ning at  the  highest  point  and  gradually  approaching  the  perineum. 
Occasionally  one  of  these  sutures  is  made  to  catch  the  connective  tissue 
over  the  rectocele  in  order  to  reef  it  upward.  As  a  rule,  this  is  not 
advisable,   as  pockets    may  be  formed,   but  with  each  successively 


TOTAL    PROLAPSE    OF    THE    UTERUS 


251 


Fig.  82.— Dissection  is  condnued  upwards  a  certain  distance,  and  is  carried  as  far  later- 
ally as  possible.  This  upper  flap  is  now  carried  down  and  split  in  the  median  line  throughout 
its  entire  e.xtent. 


TOTAL  PRO!, APSE  OF  THE  UTERUS 


253 


YiG.  83. — The  two  resulting  flaps  are  then  lifted  upward  and  the  index  finger  covered  with 
gauze  continues  the  dissection  of  the  flaps  up  toward  the  cervix  and  very  far  laterally  into  the 
sulci  of  the  vagina. 


TOTAL    PROLAPSE    OF    THE    UTERUS 


255 


Fig.  S4. — L^pward  dissection  of  the  entire  posterior  wall  is  continued  in  the  same  fashion 
with  additional  splitting  of  the  flap  when  necessarj^,  until  practically  the  entire  vaginal  wall  has 
been  freed  up  to  within  1/2  inch  of  the  cervix. 


TOTAL    PROLy\PSE    OF    THK    UTKRUS 


257 


Fig.  85. — The  two  flaps  are  then  drawn  down  and  pulled  to  the  opposite  side  in  turn,  and  then, 
beginning  from  each  volsellum  and  running  at  first  transversely  toward  the  median  line  and  then 
upward  in  a  longitudinal  fashion,  the  two  flaps  are  resected  almost  up  to  the  lateral  margins  of  the 
vagina. 


17 


TOTAL    J'ROLAPSK    OF    TIIK    UTKRUS 


259 


Fig.  86. — After  the  flaps  have  been  dissected  from  the  rectum  and  the  posterior  vaginal  wall 
is  excised  as  above,  interrupted  chromic  sutures  are  passed  uniting  the  lateral  edges  of  the  vaginal 
mucosa  beginning  above. 


TOTAL    PROLAPSE    OF    TIIK    UTERUS 


261 


Fig.  87. — After  ihe  edges  of  the  resected  posterior  \'aginal  wall  have  been  united  bv  inter- 
rupted chromic  sutures  a  large  denuded  area  is  still  left,  in  the  center  of  which  is  exposed  the 
wide  rectum  or  rectocele. 


TOTAL  PROLAPSK  OF  THE  UTERUS 


263 


Fig.  88. — A  very  long  slightly  curved  hea\y  needle  threaded  with  >,o.  4  chromic  catgut  is 
introduced  1/2  inch  from  the  skin  margin  and  external  to  the  volsellum  on  the  left  side  and  is 
passed  along  the  left  lateral  edge  of  the  denudation  under  the  levator  ani  and  under  the  vaginal 
mucosa  out  at  the  highest  point  of  the  denudation  or  near  the  lowest  applied  chromic  suture. 
Rubber  gloves  are  worn. 


TOTAL    I'ROLAPSl-:    OF    THE    UTKRUS  265 

applied    suture    the   rectocele  is  pushed  u|)ward  by  a  blunt-pointed 
instrument. 

After  several  sueh  sutures  have  been  tied,  it  will  be  noted  that 
the  vagina  has  been  reduced  to  a  canal  of  very  small  calibre  (Fig.  87), 
and  this  part  of  the  vagina  may  now  be  gently  packed  with  iodoform 
gauze.  The  lowest  of  these  interrupted  sutures  pass  not  only  througli 
the  edge  of  the  mucosa  but  deeply  under  it  to  take  up  the  muscular 
tissue  in  the  lateral  sulci.  We  now  have  left  a  large  denuded  area  with 
the  outline  of  a  rather  high  colpoperineorrhaphy  and  some  of  the  bulg- 
ing rectocele  at  the  lower  area  still  remains  to  be  dealt  with.  Inas- 
much as  the  rectocele  is  a  hernia  through  separated  or  torn  levator 
ani  muscles,  these  or  the  fascia  which  covers  them  must  be  brought 
still  further  together  in  such  a  fashion  as  to  he  between  the  new  vagina 
and  the  rectum,  to  be  in  front  of  the  rectocele,  and  hold  the  rectocele 
permanently  in  check.  Inasmuch  as  the  healing  of  such  a  large 
denuded  area  is  promoted  to  a  great  extent  by  the  use  of  the  smallest 
possible  number  of  sutures,  I  begin  the  perineorrhaphy,  with  the  very 
best  results,  with  a  No.  4  chromic  catgut  tension  suture  passed  in  the 
Waldo  figure-of-8  fashion  as  a  single  stitch. 

A  very  long  heavy  slightly  curved  needle  is  used,  the  left  index 
finger  is  introduced  for  control  into  the  rectum,  so  that  the  needle 
may  at  no  point  enter  the  lumen  (Fig.  88).  Of  course,  rubber 
gloves  are  worn.  The  highest  area  of  the  remaining  denudation  is 
brought  into  view  by  a  pair  of  forceps  applied  to  the  upper  angle, 
that  is,  to  the  last  applied  chromic  suture  which  united  the  newly  formed 
posterior  vaginal  wall.  The  needle  is  introduced  on  the  left  side,  one- 
half  inch  or  more  exterior  to  the  volsellum,  goes  in  deeply  through  the 
lateral  area  of  the  denudation  under  the  levator  ani  muscle.  It  is 
then  continued  up  along  the  left  lateral  edge  of  the  denudation  close 
along  the  vaginal  mucosa  and  comes  out  above  the  last  applied  chromic 
suture,  best  held  by  an  artery  forceps  (Fig.  81).  The  needle  is  pulled 
through  and  with  it  the  chromic  catgut.     It  is  now  introduced  on  the 


266  VAGINAL   CELIOTOMY 

other  side  of  the  median  line  and  passed  down  between  the  exposed 
connective  tissue  and  the  rectal  mucosa  over  the  finger  in  the  rectum, 
half  way  between  the  median  line  and  the  volsellum  on  the  right  side. 
As  the  needle  passes  lower  down  and  gets  within  an  inch  of  the  skin, 
it  is  passed  deeply  through  the  tissue,  coming  out  1/2  inch  from  the 
skin  margin  (Fig.  89).  The  needle  and  the  chromic  catgut  are  now 
pulled  through  and  are  passed  in  the  same  fashion,  but  from  below 
upward,  midway  between  the  median  line  and  the  volsellum  on  the 
patient's  left  side.  It  is  then  passed  upward,  the  point  of  the  needle 
being  controlled  by  the  finger  in  the  rectum,  and  makes  its  exit  at  the 
upper  angle  of  the  denudation  through  the  vaginal  mucosa  (Fig.  90). 
It  is  then  introduced  on  the  other  side  of  the  median  line,  passes  under 
the  mucosa  on  the  right  lateral  edge  of  the  denudation,  until  the  point 
reaches  the  depth  of  the  right  lateral  sulcus  and  is  thus  passed  deeply 
under  the  levator  ani  muscle  and  out  external  to  the  right  volsellum 
1/2  inch  or  more  from  the  skin  edge  (Fig.  91).  The  needle  and  chro- 
mic catgut  are  then  pulled  through.  In  order  to  make  the  union  of  the 
posterior  vaginal  wall  quite  perfect,  three  chromic  sutures  are  now 
passed  (but  not  tied)  through  the  edge  of  the  mucous  membrane 
forming  the  upper  triangle  of  the  lateral  margins  of  the  denuded  area 
and  out  through  a  corresponding  point  on  the  other  side  (Fig.  92). 

These  are  grasped  by  artery  forceps,  each  one  separately  (Fig. 
92).  Sutures  are  now  passed  to  unite  the  levatores  ani  of  the  two 
sides  and  form  a  bridge  which  is  to  firmly  restrain  the  rectocele.  One, 
two,  or  three  chromic  sutures  are  passed  by  a  well-curved  needle  deep 
through  the  lateral  sulcus  of  one  side,  in  which  rests  the  levator  ani 
and  its  covering  of  fascia,  and  then  through  the  other  side  in  the  same 
fashion  (Fig.  92).  I  have  not  found  it  necessary  to  dissect  out  through 
the  fascia  any  muscle  bundles  of  levator  ani  muscles.  These  one,  two, 
or  three  sutures  are  now  firmly  tied  in  front  of  the  rectocele  and  their 
influence  in  pushing  up  and  holding  back  the  rectocele  is  readily 
apparent  (Fig.  93).     These  are  the  only  buried  knots  in  thi-s  method 


TOTAL    PROLAPSE    OF    TFIE    UTERUS 


267 


Fig.  89. — The  needle  is  introduced  on  the  other  side  of  the  median  hne  and  passed  down 
under  the  exposed  submucous  tissue,  the  finger  in  the  rectum  guarding  against  the  penetration 
of  the  rectal  mucosa.  It  passes  down  halfway  between  the  median  line  and  the  right  edge  of  the 
perineal  denudation.  It  passes  out  1/2  inch  away  from  the  skin  edge.  (The  needle  is  depicted 
above  a  little  too  far  from  the  median  line.) 


TOTAL    PROLAPSE    OF    TTIK    I'TKRUS 


269 


YiG.  90. The  needle  enters  on  the  left  side  of  the  median  line  at  relatively  the  same  position 

at  which  it  made  its  exit  in  the  drawing  before  and  passes  up  under  the  exposed  tissue  between  it 
and  the  rectal  mucosa,  halfway  between  the  median  line  and  the  left  lateral  margin  of  the  denu- 
dation.    Its  exit  is  shown  above. 


TOTAL    l'R()l,.\l'SI';    OV    THE    UTERUS 


271 


-  Fig.  qi. — The  needle  then  enters  on  the  other  side  of  the  median  hne  and  passes  down 
under  the  vaginal  mucosa  and  then  along  the  right  lateral  edge  of  the  denudation,  passing  deeply 
so  as  to  get  under  the  levator  ani  muscle  and  then  passes  out  1/2  inch  from  the  skin  edge  and 
external  to  the  right  volsellum. 


TOTAL    PROLAPSE    OF    THE    UTERUS 


273 


Fig.  92. — Three  sutures  are  passed  through  the  \  aginal  mucosa  of  the  left  upper  lateral  edge 
of  the  denudation  and  through  the  right  upper  edge  of  the  denudation  and  grasped  by  artery- 
forceps.  These  are  tied  after  all  the  other  sutures  are  tied  and  simply  bring  the  vaginal  mucosa 
of  the  new  posterior  vaginal  wall  neatly  together.  At  the  same  time  a  short-curved  needle  takes 
a  deep  bite  through  the  levator  ani  muscle  in  the  left  lateral  sulcus,  and  is  shown  above  in  the  act 
of  taking  a  like  deep  bite  in  the  right  lateral  sulcus.  One,  two  or,  better,  three  such  sutures  are 
passed. 


18 


TOTAL    PKOLAPSE    OT    THE    UTERUS 


275 


Fig.  93. — The  above  drawing  shows  how  one  of  the  sutures  passed  through  the  levatores 
ard  muscles  in  the  lateral  sulci,  when  tied,  forms  a  bridge  over  the  rectocele  and  pushes  it  back  in 
hour-glass  fashion.  Before  tying  this  one,  two  others  have  been  passed,  one  higher  up  and  one 
lower  down  through  the  lateral  sulci.  Only  one  is  tied  in  the  above  draT\ing  to  show  the  method 
of  its  action.  The  three  sutures  held  in  the  upper  part  of  the  drawing  by  artery  forceps  are  tied 
after  the  long  figure  of  8  chromic  suture  is  tied.  Before  tjing  the  long  chromic  No.  4  suture,  the 
two  volsella  are  removed  and  a  pair  of  artery  forceps  is  applied  to  the  middle  of  the  denuded 
posterior  edge,  and  then  the  long  No.  4  chromic  suture  is  tied  by  pulling  it  in  see-saw  fashion. 


TOTAL    PROLAPSE   OF   THE   UTERUS 


27: 


Fig.  94. — After  the  tying  of  the  long  No.  4  chromic  catgut  suture,  two  or  three  other  sutures 
are  passed  through  the  perineal  skin  edges  and  the  three  intravaginal  sutures  are  tied. 


TCrrAL    IMUJLAPSE   OF    THE   UTERUS 


279 


Fig.  95. — As  the  last  step  in  the  operation,  the  sphincter  ani  is  stretched  very  thoroughly. 
This  permits  the  bowels  to  move  daily  without  discomfort  to  the  patient  and  without  any  harmful 
effect  on  the  perineorrhaphy.  The  perineum  is  douched  with  a  pitcher  of  sterile  solution 
several  times  a  day,  especially  after  urination  or  defecation.  Plenty  of  sterile  gauze  is  applied 
over  the  vulva  and  frequently  changed.     No  infection  occurs. 


TOTAL    PROJ.AFSK    OF    THE   UTERUS  25 1 

of  perineorrhaphy.  A  pair  of  artery  forceps  is  now  applied  to  the 
middle  point  of  the  skin  edge,  the  two  ends  of  the  long  single-stitch 
chromic  suture  are  pulled  on,  in  see-saw  fashion,  gently  but  firmly, 
and  that  part  of  the  single-stitch  suture  which  has  passed  from  one 
side  to  the  other  over  the  skin  edge  is  seen  to  take  its  place  at  a  point 
almost  midway  between  the  entrance  points  of  the  suture  held  in  the 
hands,  and  the  artery  forceps  applied  to  what  is  now  becoming  the 
lowest  point  of  the  external  perineal  wound  (Fig.  93). 

When  the  two  ends  have  thus  been  pulled  on,  the  two  lateral  sides 
of  the  perineal  denudation  come  together  in  absolute  contact  and 
a  triple  knot  is  tied  and  cut.  Then  the  three  chromic  sutures  which 
were  passed  and  held  by  a  pair  of  forceps  are  tied.  They  unite  the 
lower  end  of  the  new  posterior  vaginal  wall.  Two  or  more  chromic 
sutures  are  now  introduced  in  the  perineum  itself  (Fig.  94),  to  bring  the 
skin  edges  nicely  together,  and  the  patient  is  catheterized.  Strips  of 
iodoform  gauze  are  tucked  into  the  vagina  and  the  sphincter  ani  is 
given  a  most  thorough  stretching  (Fig.  95).  Then  iodoform  gauze  is 
applied  liberally  over  the  vulva  and  perineum,  and  is  renewed  with 
sufficient  frequency  to  keep  this  area  very  dry.  The  perineum  is 
douched  several  times  daily,  especially  after  catheterization  or  defeca- 
tion, with  a  quart  pitcher  full  of  sterile  aluminum  acetate  solution. 
Catheterization  is  continued  for  three  or  four  days  and  the  patient  is 
then  allowed  to  void  if  she  can.  The  bowels  are  permitted  to  act 
as  soon  as  the  patient  is  so  inclined.  As  a  rule  a  cathartic  is 
administered  per  os  on  the  third  or  fourth  day. 

The  intrauterine  strip  of  gauze,  which  is  usually  marked  by  having 
a  piece  of  chromic  catgut  tied  around  the  end,  is  pulled  out  without 
disturbing  the  vaginal  packing  on  the  third  or  fourth  day.  The 
vaginal  packing  of  iodoform  gauze  is  allowed  to  remain  from  five 
to  eight  days. 

This  operation  is  attended  with  a  minimum  of  shock,  the  pulse 
rate  in  very  few  instances  being  over  90  on  completion  of  operation. 


262  VAGINAL   CELIOTOMY 

Utilizing  the  vagino-fixation  principle  of  Diihrssen,  the  points 
of  importance  are : 

1.  Free  separation  of  the  bladder. 

2.  Great  resection  of  the  anterior  and  lateral  vaginal  walls,  asso- 

ciated with  special  method  of  high  amputation  and  of  attach- 
ment of  the  vaginal  mucosa  around  the  cervix. 

3.  Removal  of  posterior  enterocele. 

4.  Free  separation  of  the  rectum  from  the  posterior  vaginal  wall. 

5.  Wide  resection  of  the  posterior  vaginal  wall. 

6.  High   perineorrhaphy   resulting    in    small    introitus    and   firm 

union   of  levator  ani  muscles   to  hold  back   the   redundant 
rectum. 

RESULT. 

The  uterus  is  diminished  in  size  and  the  big,  long  cervix  with 
much  portio  mucosa  is  removed.  The  small  uterus  lies  anteverted 
and  behind  the  symphysis,  and  the  uterus  is  fixed  to  the  narrowed 
anterior  vaginal  wall.  The  cervix  when  amputated  has  the  internal 
OS  thrown  very  high  up  and  back.  The  narrowed  upper  vaginal 
lumen  and  the  upper  posterior  fornix  (so-called)  are  carried  high 
up  by  the  external  os  of  the  new  cervix. 

A  narrow  vagina  is  produced  by  resection  of  the  posterior  vaginal 
wall.  The  cure  of  rectocele  is  guaranteed  by  the  union  of  the  levator 
ani  muscles  and  by  a  high  perineorrhaphy. 

This  operation  for  prolapse  restores  the  genital  organs  to  an 
absolutely  normal  position,  leaves  a  splendid,  firm  perineum,  an 
exceedingly  small  introitus,  and  a  vaginal  canal  longer  than  the  average. 


SIMPLE  VAGINAL  HYSTERECTOMY. 

Simple  vaginal  hysterectomy  is  an  operation  which  should  he  so 
carried  out  as  to  remove  only  the  uterus.  It  should  Ije  so  planned 
as  to  make  the  procedure  as  safe  as  any  major  operation  in  gynecology. 
It  is  indicated  in  conditions  of  the  uterus  in  which  malignancy  is 
excluded.  It  can  be  used  for  fibroid  tumors  of  the  uterus,  if  the 
uterus  is  not  too  large  to  be  delivered  into  the  vagina.  On  comple- 
tion of  this  method  of  hysterectomy  the  tubes  and  ovaries  may  be 
removed,  with  any  desired  area  of  the  upper  part  of  the  broad  liga- 
ment. This  extended  phase  of  simple  hysterectomy  applies  to  early 
cases  of  carcinoma  of  the  fundus  uteri :  those  cases  which  develop 
parametritic  infiltration  so  late  that  hysterectomy  offers  a  favorable 
hope  of  cure.  The  important  indication  for  the  simple  operation  in- 
cludes intractable  hemorrhages  from  the  uterus  which  do  not  yield 
to  conservative  methods.  These  conditions  are,  in  addition  to  fibroids 
and  polyps,  arteriosclerosis  of  the  uterine  vessels,  myometrial  de- 
generations, and  fibrosis  uteri. 

There  is  a  condition  of  the  uterus,  to  which  I  have  given  the  name 
fibrosis  uteri  characterized  by  a  diffuse  fibrotic  change  in  the  entire 
thickness  of  the  uterine  wall  and  in  the  cervix,  as  a  result  of  which  the 
uterus  is  elongated,  wider,  and  thicker  than  the  normal.  This  fibrotic 
alteration  is  recognized  during  operation  by  the  fact  that  the  vol- 
sellum  forceps,  when  grasping  the  uterine  wall,  break  through  it  because 
of  the  brittleness  of  the  tissue,  and  the  pale  pinkish-yellow  color  of  the 
broken  areas  resembles  in  every  particular  the  appearance  noted  in 
fibroids  in  the  uterus. 

Microscopic  sections  show  the  muscularis  to  be  invaded  by  regular 
and  irregular  bundles  of  fibrous  connective  tissue,  so  that  in  many 
areas  this  tissue  fills  the  entire  field  of  observation.  Arteries  and  veins 
are  very  much  dilated,  their  walls  are  thickened,  and  frequently  the 

283 


284  VAGINAL   CELIOTOMY 

intima  shows  alterations  of  a  typical  nature.  The  contractility  of 
the  muscle  fibers  is  altered,  the  interstices  have  been  filled  by  this  new 
growing  tissue,  and  combined  with  this  is  a  disappearance  of  the  numer- 
ous elastic  fibers  of  the  uterus.  The  uterus  has  lost  its  contractile 
power,  the  vessels  have  been  affected  in  a  like  manner,  and  the  added 
loss  of  the  contractile  force  of  the  elastic  fibers  tends  to  a  ready  bleeding 
from  the  uterine  muscosa  and  to  diminished  ability  to  control  this 
bleeding. 

The  premenstrual  congestion  which  takes  place  throughout  the 
whole  genital  tract,  and  especially  in  the  uterine  wall  and  in  the  mucosa, 
normally  comes  to  a  climax  slowly  and  steadily.  The  final  result  of 
the  congestive  climax  is  the  outpouring  of  blood.  The  normal  uterus, 
with  well-conditioned  muscle  fibers,  with  elastic  connective  tissue,  and 
with  elastic  arterioles,  resists  for  a  period  of  twenty-eight  days  this 
congestion  which  ends  in  the  expulsion  of  blood.  Such  a  normal 
uterus  limits  the  hemorrhage  within  the  course  of  four  or  five  days  by 
the  contractility  of  the  muscular  fibers,  of  the  elastic  fibers,  and  of  the 
atrterioles. 

If  the  muscular  fibers,  the  elastic  fibers,  or  the  vessels  have  lost 
to  a  greater  or  lesser  degree  their  ability  to  contract  or  their  abihty  to 
resist  the  congestive  influence  of  the  premenstrual  period,  bleeding 
either  comes  on  sooner  or,  when  it  comes,  lasts  longer.  This,  of  course, 
implies  well-functionating  ovaries  producing  the  congestion  which  char- 
acterizes menstruation.  The  vast  majority  of  these  cases  show  ovaries 
which  are  large  and  plump.  They  evidence  numerous  follicles  and 
possess  the  full  power  of  the  ovarian  secretion  to  promote  pelvic  conges- 
tion. As  a  result  of  structural  fibrotic  uterine  changes,  since  the 
ovaries  are  functionating,  the  menstrual  congestion  results  in  increased 
frequency  of  menstruation,  in  increased  loss  of  blood,  and  in  increased 
duration  of  the  menstrual  function.  In  many  cases  menstruation  is 
no  longer  regular,  passing  from  the  type  of  menorrhagia  to  the  type 
of  metrorrhagia.  Most  of  these  cases  of  fibrosis  occur  in  women 
in    the   late     thirties    and    in   the   forties.     These    women    are   ro- 


SIMPLE    VAGINAL  HYSTERECTOMY  285 

bust  and  well-built,  and  the  menopause,  if  allowed  come  of  its  own 
accord,  may  only  result  after  the  lapse  of  many  years. 

As  a  result  of  the  increased  loss  of  blood  and  the  tendency  to  the 
formation  of  clots,  the  blood  does  not  find  ready  exit  through  the  cer- 
vical canal,  tlie  walls  of  which  are  hard  and  fibrotic;  painful  menstrua- 
tion is  a  very  frequent  complication.  Nervous  phenomena  of  pro- 
nounced type  are  among  the  annoying  symptoms.  There  occurs  in 
many  cases  what  may  be  known  as  constitutional  dysmenorrhea. 
For  several  days  before  menstruation  and  during  the  menstrual  period 
congestion  involves  the  entire  nervous  system,  the  various  mucosae  of 
the  body,  and  produces  a  sensation  of  fullness  in  the  head,  dizziness, 
nausea,  anorexia,  irritability,  palpitation  of  the  heart,  restlessness,  and 
sleeplessness.  The  annoying  symptoms,  the  painful  menstruation,  and 
the  great  loss  of  blood  often  reduce  these  patients  to  a  state  of  marked 
physical  and  nervous  asthenia.  While  in  many  instances  this  uterine 
and  constitutional  condition  results  after  two  or  three  labors,  in  the 
majority  of  cases  there  is  a  history  of  frequent  labors  and  often  of 
several  abortions.  In  all  probability  the  element  of  subinvolution 
after  frequent  labors  or  abortions  plus  the  associated  congestion 
resulting  therefrom  are  the  etiological  factors  which  lead,  after  the  lapse 
of  several  years,  to  fibrotic  structural  changes  in  the  tissue  elements 
which  make  up  the  uterine  wall.  Prolonged  congestion  in  the  pelvis, 
altered  circulation  in  the  uterus  and  adnexa,  and  a  general  state  of 
altered  elasticity  are  associated  factors.  There  seems  to  be  in  certain 
women  a  tendency  to  an  alteration  of  the  normal  elastic  fibers  of  the 
uterus  and  to  their  replacement  by  fibrous  connective  tissue,  a  condition 
which  was  well  illustrated  microscopically  by  the  investigations  of 
Pick.  The  uterine  mucosa  is,  as  a  rule,  in  these  cases,  not  hyper- 
plastic, so  that  hyperplasia  of  the  endometrium  is  not  an  important 
point  in  the  causation  of  these  prolonged  profuse  bleedings. 

The  medical  treatment  of  this  fibrotic  alteration  of  the  uterus 
includes  anything  which  may  increase  the  contractile  power  of  the 
uterus,  which  mav  diminish  the  size  of  the  uterus,  which  mav  diminish 


286  VAGINAL   CELIOTOMY 

the  congestion  in  the  uterus  and  in  the  pelvic  structures.  Among  the 
drugs  which  are  of  value  are  the  various  preparations  of  ergot,  styp- 
ticin,  etc.  Among  the  therapeutic  measures  are  the  intrauterine  use 
of  the  positive  electrode,  the  use  of  short,  hot  douches,  the  regular  and 
systematic  daily  use  of  sitz  baths  of  such  temperatures  as  tend  to 
permanently  diminish  the  pelvic  congestion. 

Among  the  milder  operative  procedures  are  to  be  included  very 
thorough  curettage  and  the  use  of  steam  with  or  without  the  prehmi- 
nary  use  of  the  curette.  With  any  of  these  various  combinations  plus 
rest  and  the  avoidance  of  exertion,  particularly  before  and  during  the 
flow  of  blood,  many  of  these  patients  may  be  so  markedly  improved 
after  months  or  years  that  further  intervention  may  be  avoided.  In 
many  of  these  cases,  even  after  temporary  improvement  of  various 
durations,  the  trying  annoyances  recur.  In  a  goodly  proportion  of 
cases  the  patients  belong  to  that  social  scale  which  precludes  the 
possibility  of  rest  and  the  avoidance  of  exertion.  Thereby  one  of  our 
most  important  therapeutic  measures  is  denied  us.  In  other  cases  the 
patients  find  that  the  treatment  which  is  necessary  and  the  rest  which  is 
demanded  interferes  too  much  with  their  family  and  social  obligations 
and  prevents  the  leading  of  a  life  which  is  pleasurable  and  enjoyable. 

The  remedy  which  absolutely  prevents  the  various  combinations  of 
symptoms  is  vaginal  hysterectomy  without  the  removal  of  the  ovaries. 
In  this  way  unbearable  hemorrhage  is  prevented  and  the  regular  or 
irregular  recurrence  of  the  condition  known  as  constitutional  dysmenor 
rhea  is  at  an  end.  (Retention  of  the  ovaries  avoids  the  recurrence  of 
constitutional  symptoms  of  the  climacterium.) 

Operation. — The  following  method  of  simple  vaginal  hysterectomy 
is  practised  by  me :  The  cervix  is  grasped  by  a  heavy  pair  of  volsellum 
forceps  and  is  pulled  forward  so  that  its  posterior  wall  is  exposed.  A 
transverse  incision  is  made  through  the  vaginal  mucosa  about  i  inch 
above  the  external  os.  The  upper  margin  of  the  incision  is  grasped 
by  a  long  mouse-tooth  forceps  and  a  pair  of  scissors  dissects  off  the 
vaginal  mucous  membrane  by  short  snips  passing  through  the  connective 


SIMPLE   VAGINAL  HYSTERECTOMY 


287 


Fig.  96. — Vagixal  Hysterectomy. 


A  transverse  incision  is  made  in  the  posterior  fornix  not  an  inch  away  from  the  external  os. 
A  pair  of  artery  forceps  grasps  the  upper  lip  of  the  incision  and  dull-pointed  scissors  snip  the  bands 
connecting  it  with  the  cervix. 


SIMI'LK    VAOINAL   IIYS'ri:R  IvCTC^MY 


289 


Fig.  97. — Vaginal  Hysterectomy. 

The  index  finger  covered  with  gauze  rubs  the  mucosa  of  the  posterior  fornix  away  from 
the  cervix  up  to  the  cul  de  sac  of  Douglas,  and  then  pushes  the  Douglas  peritoneum  upward  to 
separate  it  still  further  from  the  cervico-uterine  area. 


19 


SIMPLIO    VAGINAL  II YSTJCRICCTOAI Y  291 

tissue  bands  whicli  connect  the  vaginal  mucosa  to  the  structure  of 
the  cervix  (Fig.  96).  A  long  pair  of  artery  forceps  then  grasps  this 
upper  margin  of  the  posterior  incision  and  the  finger  separates  the 
vaginal  mucosa  and  the  connective  tissue  still  further  from  the  cervix. 
The  cul  de  sac  of  Douglas  is  distinctly  felt  (Fig.  97).  The  cul 
de  sac  of  Douglas  is  then  incised,  or  perforated  with  the  index  finger 
(Fig.  98),  the  finger  is  introduced  into  the  peritoneal  cavity  and 
the  peritoneum  is  hooked  by  the  finger  tip  and  brought  down  so 
that  a  long  pair  of  forceps  placed  at  the  lateral  margin  of  the  incision 
unites  the  peritoneum  with  the  edge  of  the  vaginal  mucosa  (Fig.  99). 
The  same  thing  is  done  on  the  other  side,  so  that  the  peritoneum 
and  vaginal  mucosa  are  held  together  at  the  lateral  borders  of  the 
primary  incision.  These  two  forceps  are  of  importance  in  that  each 
limits  the  bleeding  to  a  marked  degree  and  serves  to  mark  a  point 
around  which  one  of  the  final  closing  sutures  is  passed.  The  next 
step  consists  in  making  a  transverse  incision  on  the  anterior  wall 
of  the  cervix,  the  ends  of  which  almost,  but  not  quite,  join  the  ends 
of  the  posterior  incision.  Two  artery  forceps  are  applied  to  the 
middle  point  of  the  upper  lip  of  this  incision  and  by  traction  the  con- 
nective tissue  bands  which  unite  the  bladder  to  the  anterior  wall  of 
the  cervix  are  brought  into  relief.  Some  of  these  are  cut  with  snips 
of  the  scissors,  and  then  the  index  finger,  covered  with  gauze,  separates 
the  bladder  from  the  anterior  wall  of  the  cervix  and  uterus  up  to  the 
vesico-uterine  pouch  of  peritoneum.  The  two  anterior  artery  forceps 
being  then  put  on  the  stretch,  a  pair  of  long  sharp-pointed  scissors 
is  introduced  between  the  vaginal  mucosa  and  the  bladder  and  the 
anterior  vaginal  wall  is  progressively  incised  for  a  longitudinal  distance 
of  3  1/2  to  4  1/2  inches.  Each  artery  forceps  is  then  grasped  in  turn 
and  with  a  slight  rotation  the  vaginal  mucosa  is  everted;  a  few  snips 
with  the  scissors  starts  the  separation  of  the  bladder  from  the  vaginal 
mucosa  and  the  subsequent  complete  separation  of  the  bladder  from  the 
vaginal  wall  is  carried  out  with  the  index  finger  covered  with  anterior 


292  VAGINAL   CELIOTOMY 

gauze.  These  steps  are  the  same  as  those  in  the  performance  of  anterior 
vaginal  cehotomy  or  vaginal  fixation  for  prolapse  of  the  uterus.  These 
steps  being  completed,  the  bladder  itself  is  held  back  by  a  retractor. 
In  a  proportion  of  cases  the  uterine  artery  can  be  either  seen  or 
readily  felt  on  either  side  after  thorough  separation  of  the  bladder 
(Fig.  100). 

A  ligature  needle,  threaded  with  large-sized  silk  or  chromic,  is 
then  passed  through  the  lower  border  of  the  broad  hgament  close 
to  the  uterus  and  below  the  pulsating  artery  (Fig.  102).  The  ligature 
passes  out  through  the  posterior  incision  in  the  peritoneum  and  is 
tied  very  firmly  over  the  bridge  of  uncut  mucosa  forming  the  lateral 
covering  of  the  cervix.  Before  tying  this  hgature,  a  slight  snip  is 
made  in  the  vaginal  mucosa  to  furnish  a  groove  in  which  this  liga- 
ture and  its  knot  may  rest  to  prevent  slipping  in  the  course  of  the 
subsequent  manipulation  (Fig.  103). 

The  long  retractor,  which  pushes  the  bladder  upward,  makes 
it  easy  for  the  uterine  artery  to  be  located  by  the  finger  just  above 
the  first  hgature  that  has  been  passed.  A  second  hgature  is 
passed  just  above  the  uterine  artery  which  is  sometimes  exposed  to 
the  eye  (Fig.  104)  and  the  end  is  brought  out  through  the  posterior 
incision,  and  the  ligature  tied  i  inch  above  the  first  one  (Fig.  105); 
another  groove  being  made  in  the  vaginal  mucosa  with  the  scissors  to 
prevent  slipping  of  the  ligature.  The  same  procedure  is  then  repeated 
on  the  opposite  side,  after  which  a  pair  of  scissors  cuts  between 
the  fastened  silk  sutures  and  the  lateral  borders  of  the  uterus,  stick- 
ing very  close  to  the  cervix  (Fig.  106). 

The  scissors  cut  up  toward  the  uterine  artery.  Very  short  snips 
should  be  taken  so  that  the  uterine  artery  may  be  recognized  before 
it  is  cut,  if  it  lies  deeply  within  the  tissues  which  are  being  cut  (Fig. 
107).  Usually  it  lies  close  to  the  surface.  In  either  event,  if  possi- 
it  should  be  tied  again  before  being  cut  through.  This  step  is  of 
value,  for  if  by  any  chance  the  uterine  artery  has  not  been  caught 


SIMPLE    VAGINAL  HYSTERECTOMY 


293 


Fig.  98. — \'aginal  Hysterectomy. 


The  peritoneum  of  the  cul  de  sac  of  Douglas  is  then  grasped  with  forceps  and  cut  through 
with  scissors,  or  else  the  peritoneum  is  perforated  b}'  the  left  index  finger.  The  latter  manipula- 
tion is  the  more  simple  in  those  cases  where  the  cervix  is  not  readily  brought  down  near  the  vulva. 


SIMIM.!'-.    \'A(;i.\.\l.    IIVSTKRFXTOMY 


295 


Fig.  9q. — Vaginal  Hysterectomy. 


With  either  of  the  aforesaid  manipulations  the  posterior  peritoneal  edge  is  caught  with  the 
index  finger  and  brought  down  into  apposition  with  the  incision  in  the  vaginal  mucosa  and  the 
peritoneum  and  the  vaginal  edge  are  caught  and  held  together  by  a  long  artery  forceps  or  clamp 
applied  at  the  Extreme  end  of  the  transverse  incision.  The 'process  is  repeated  on  the  other  side 
and,  if  desired,  another  forceps  or  clamp  may  be  applied  midway  between  the  two.  In  some  cases 
it  may  be  advisable  to  substitute  these  clamps  or  forceps  by  mattress  sutures  in  order  to  unite 
the  peritoneum  with  the  vaginal  edge  and  thus  stop  the  oozing  from  this  posterior  incision  which 
sometimes  seems  rather  profuse. 


SIMPLE    VAGINAL   HYSTICR  IX'TOMY 


297 


Mf^ 


-JS  0-5-^4:-. 


Fig.  100. — ^Vaginal  Hysterectomy. 


The  cervix  is  then  pulled  down  toward  the  perineum  and  the  bladder  is  thoroughly  dissected 
away  from  the  cervix  and  the  uterus  and  the  anterior  fornix  in  the  manner  described  in  figures 
18  and  27,  which  finally  gives  us  the  picture  noted  above.  The  bladder  is  held  up  out  of  the  way 
by  the  anterior  retractor.  The  vesico-uterine  plica  is  seen  beneath  it.  Laterally,  the  location 
of  the  uterine  arteries  is  clearly  portrayed. 


SIMPLE   VAGINAL  HYSTERECTOMY 


299 


Fig.  ioi. — ^Vaginal  Hysterectomy. 

After  completion  of  these  steps  and  before  the  vesico-uterine  perineum  is  opened  the  liga- 
tion of  the  lower  part  of  the  broad  ligaments  including  the  uterine  arteries  is  begun.  It  is  possible 
to  make  an  incision  through  the  vaginal  mucosa  which  bridges  the  area  between  the  exposed  ante- 
rior wall  of  the  cervix  and  uterus  and  the  incised  cul  de  sac  of  Douglas  and  peel  it  back  up  to  the 
uterine  arter)^  I  prefer  to  ligate  this  area  by  a  special  method  in  order  to  keep  the  uterine  arter}' 
and  its  accessor}^  vessels  from  retracting. 


SIMPLE   VAGINAL  HYSTERECTOMY 


3Pi 


A'^ 


m  w 


Fig.  102. — ^Vaginal  Hysterectomy. 

A  ligature  carrier  threaded  with  heavy  chromic  or  heavy  braided  silk  is  passed  from  before 
backward  on  the  left  index  finger  which  has  been  introduced  into  the  peritoneal  cavity  through  the 
posterior  incision.  The  bladder  if  possible  is  held  up  and  out  of  the  way  by  a  narrow  anterior 
speculum.  If  no  anterior  speculum  is  introduced,  care  must  be  taken  to  see  that  the  ligature 
carrier  passes  close  to  the  lateral  border  of  the  cervix  and  does  not  include  the  separated  bladder. 


SIMPLE    VAdlNAL  HYSTERIX'TOMY 


3^3 


Fig.   103. — ^\^JiGixAL  Hysterectomy. 

After  tension  on  the  cervix  is  relaxed  a  superficial  cut  is  made  in  the  lateral  border  of  the 
vaginal  mucosa  and  in  this  cut  the  ligature  is  to  be  tied.     This  prevents  slipping  of  the  ligature. 


SIMIM.I'.    \A(;i.\AL  HYSTERECTOMY 


305 


j^o^si^- 


FiG.   104. — ^\'aginal  Hysterectomy. 


The  second  suture  passed  by  the  ligature  carrier  is  introduced  an  inch  or  so  higher  than  the 
first  and  passes  above  the  uterine  artery,  which  is  either  seen  or  felt  by  the  right  index  finger,  or 
is  felt  between  this  finger  and  the  left  index  finger  introduced  posteriorly. 


si.MiM.i';  \A(;i.\Ai.  insi'i;Ri;("i().M\' 


307 


Fig.   iov — Vaginal  Hysterectomy. 


After  this  is  pas.sed  another  superficial  groove  is  made  in  the  lateral  bridge  of  the  vaginal 
mucosa  and  after  tension  on  the  cervix  has  been  relaxed  this  important  chromic  or  silk  ligature 
is  tied  with  the  greatest  possible  force. 


SIMPLE   VAGINAL  HYSTERECTOMY 


309 


Fig.  106. — ^\'AGiNAL  Hysterectomy. 


This  procedure  having  been  carried  out  on  one  side,  is  then  repeated  on  the  other  side  before 
any  cutting  is  done  or  else  the  lower  part  of  the  broad  ligament  is  cut  away  from  the  cer\"ix,  after 
which  two  sutures  are  passed  on  the  other  side  through  the  base  of  the  broad  ligament. 


SIM  I'M'.    \\c;i\A[,   Tn'STKKF.CTO.MY 


311 


P'iG.   107. — Vaginal  Hysterectomy. 


The  cutting  on  either  side  goes  very  close  to  the  cervix  with  very  short  snips  upward  until  the 
uterine  arten,-,  usually  very  tortuous  and  twisted,  is  seen  either  superficially  or  somewhat  deeper 
in  the  structure  of  the  broad  ligament  itself.  As  soon  as  the  uterine  artery  is  seen,  the  bladder 
being  kept  up  out  of  the  way  by  an  anterior  speculum,  the  ligature  carrier  threaded  with  chromic 
catgut  or  a  small  curved  needle  is  passed  about  the  uterine  artery  and  tied  in  order  to  firmly  control 
this  vessel  if  by  any  chance  the  second  silk  or  chromic  ligature  has  not  included  it. 


SIMPLE   VAGINAL  HYSTERECTOMY 


3'^3 


Fig.  ioS. — ^\'aginal  Hysterectomy. 


After  the  anterior  and  posterior  vaginal  incisions  have  been  made  the  lateral  bridge  of 
vaginal  mucosa  may  be  incised  with  scissors  and  dissected  upward  with  the  gauze-covered  thumb 
or  index  finger.  Then  the  first  chromic  suture  or  ligature  is  passed  about  the  exposed  uterine 
artery  and  tied,  and  the  ends  are  threaded  in  a  needle  and  passed  through  the  lateral  bridge  of 
vaginal  mucosa.  Another  chromic  ligature  is  passed  about  the  uterine  artery  and  tied.  After 
cutting  between  the  uterus  and  these  ligatures,  the  one  passing  through  the  mucosa  is  knotted. 


S].M1M,K  VA{;iXAl.   n\sri;Ri:("io.MY 


315 


Fig.  ioq. — \'agi.\al  Hysterectomy. 


The  separation  of  the  ligamentum  cardinale  from  the  uterus  is  carried  on  with  short  snips  of 
scissors  and  the  uterine  arteries  are  inspected.  This  is  the  most  important  part  of  the  operation, 
for  if  the  uterine  arteries  of  both  sides  have  been  thus  controlled  with  the  aid  of  sight,  that  most 
annoying  complication  of  retraction  and  bleeding  of  this  vessel  has  been  obviated. 


SIMPLE   VAGINA].    H VSTERKCTOMY 


317 


Fig.  1 10. — ^\'agix.^l  Hysterectomy. 


The  vesico  uterine  peritoneum  is  now  incised  either  by  a  wide  transverse  cut  or  by  a  combina- 
tion of  transverse  and  longitudinal  incisions. 


SIMPLI'.    \'AOI.\\L   HVSTKRF.CTOMY 


319 


P'iG.  III. — ^Vaginal  Hysterectomy. 


The  operation  is  now  continued  by  the  delivery  of  the  uterus.  The  anterior  speculum  is 
introduced  through  the  incised  peritoneum  and  the  bladder  is  held  up  out  of  the  way,  a  volsellum 
is  applied  to  the  corpus  uteri  at  the  highest  accessible  point.  If  by  any  chance  it  is  impossible 
now  to  deliver  the  fundus,  the  broad  ligament  can  be  tied  oS  by  successive  sutures  applied  from 
below  upward,  for  even  with  the  most  rigidly  fixed  uterus  of  this  class  the  preliminary  separation 
of  the  ligamentum  cardinale  brings  the  cervix  down  and  out  close  to  the  vulva. 


SIMin.E   VAGINAL  HYSTERECTOMY  32 1 

by  the  second  ligature  applied  as  in  figure  105,  it  is  essential  that 
it  be  ligated  separately,  and  if,  as  in  the  vast  majority  of  instances, 
the  uterine  artery  is  caught  ]jy  the  second  ligature,  the  additional 
tying  of  the  artery  doubly  insures  one  against  any  possible  subsequent 
bleeding  (Fig.  107). 

The  lower  part  of  the  broad  ligament  including  the  uterine  arteries 
may  be  ligated  by  another  method  (Fig.  108).  If  the  bridge  of  mucosa 
which  covers  the  lateral  wall  of  the  cervix  and  which  is  still  uncut  is 
incised  with  the  scissors  down  to  the  structure  of  the  cervix,  it  can  be 
peeled  up  very  readily  to  the  level  of  the  internal  os  by  the  gauze-covered 
thumb  without  much  bleeding  or  oozing  until  the  region  of  the  uterine 
arteries  is  reached.  If  then  this  dissected  piece  of  mucosa  with  its 
underlying  parametritic  connective  tissue  is  drawn  to  one  side  by  an 
artery  forceps,  the  uterine  artery  usually  lies  exposed  to  the  eye;  if  not, 
dissection  carries  us  up  to  it  very  easily.  It  is  then  tied  with  a  chromic 
catgut  suture  and  then  another  chromic  catgut  suture  is  tied  about 
it.  The  ends  of  one  are  threaded  into  a  needle  and  are  then  passed 
out  through  this  lateral  bridge  of  mucosa,  as  shown  in  figure  108. 
When  the  uterine  artery  is  then  cut  between  the  sutures  and  the  uterus, 
these  two  ends  are  tied  and  the  uterine  artery  is  thus  attached  firmly 
to  this  lateral  vaginal  flap  so  that  its  retraction  is  impossible.  This 
is  an  added  protection  against  subsequent  bleeding  and  serves  to 
attach  part  of  the  ligamentum  cardinale  to  the  vagina. 

After  this  step  has  been  carried  out  the  peritoneal  cavity  is  entered 
anteriorly  by  a  transverse  incision  of  the  vesico-uterine  pouch  of  perit- 
oneum (Fig.  no).  An  anterior  speculum  is  then  introduced  within 
the  peritoneum  and  the  anterior  wall  of  the  uterus  is  grasped  by  a 
pair  of  volsellum  forceps  (Fig.  in).  The  cervix  is  now  pushed  back 
into  the  vagina,  a  wider  speculum  is  introduced  into  the  peritoneal 
cavity  and  the  fundus  is  drawn  out  by  successively  applied  volsellum 
forceps  (Fig.  112)  until  the  fundus,  tubes  and  ovaries  lie  outside  of 
the  vulva.     Three  heavy  ligatures  are  then  applied  on  either  side 


322  VAGINAL   CELIOTOMY 

to  absolutely  ligate  the  broad  ligament.  The  first  one  is  applied 
near  the  fundus  and  takes  in  about  one-third  of  the  width  of  the 
broad  ligament;  the  second  is  applied  external  to  this,  taking  in  two- 
thirds  of  the  width  of  the  broad  ligaments,  and  the  third,  external 
to  this  one,  takes  in  the  entire  width  of  the  remaining  uncut  part  of 
the  broad  ligament  (Figs.  113-116).  The  scissors  then  cat  close  to 
the  body  of  the  uterus  till  one  side  of  this  organ  is  completely  severed 
from  all  attachment  to  the  broad  hgament  (Figs.  114-115).  The 
uterus  is  then  pulled  out  beyond  the  vulva  and  the  broad  ligament 
of  the  other  side  is  ligated  (Fig  116).  When  this  is  done,  the 
uterus  is  cut  off  and  removed,  the  scissors  passing  close  to  the  uterine 
structure  as  in  Figs.  114-115.  Both  uterine  arteries  have  already  been 
thoroughly  tied  and  fastened  to  the  lateral  margins  of  the  vaginal 
wall.  The  upper  part  of  the  broad  ligament,  including  the  outer  half 
of  the  tube,  the  ligament  of  the  ovary  and  the  ovarian  arteries  forms 
a  thick,  compact  band,  held  on  either  side  by  the  three  sutures.  Any 
small  bleeding  points  anywhere  are  now  caught  and  tied,  and  the 
operation  is  practically  completed. 

A  long  strip  of  iodoform  gauze  is  now  introduced  into  the  perit- 
oneal cavity  to  hold  the  intestine  and  omentum  up  out  of  the  field 
of  operation.  A  No.  3  chromic  gut  suture  is  now  taken,  and  with 
the  aid  of  a  heavy  curved  needle  is  passed  as  follows:  It  passes 
through  the  lateral  margin  of  the  longitudinal  vaginal  incision  almost 
at  its  upper  end;  it  then  catches  the  ligament  of  the  ovary  and  the 
broad  ligament  on  its  median  side  just  near  the  attachment  of  the 
ligamentum  ovarii  to  the  ovary  and  well  above  the  outermost  broad 
ligament  ligature.  It  then  passes  through  the  posterior  vaginal  wall 
and  its  attached  peritoneum  just  median  to  the  posterior  clamp  intro- 
duced at  the  beginning  of  the  operation  (Fig.  118).  It  then  passes 
through  the  lateral  vaginal  wall  1/2  inch  above  the  ligature  which 
caught  the  uterine  artery  (Fig.  119).  The  ligatures  on  the  broad 
ligament  are  pulled  down  and  then  this  suture  is  drawn  taut  and 


siMiM.i';  vAcwxAi,  iivs'ii;ri;(tomy 


323 


Fig.  112. — ^\''aginal  Hysterectomy. 


The  volsella  are  applied  in  succession  to  the  higher  areas  of  the  fundus  and  at  the  same  time 
the  cervix  is  pushed  back  thoroughly  into  the  vagina  over  the  face  of  the  posterior  speculum  until 
the  cervix  disappears  in  the  vagina  and  the  fundus  is  brought  out  beyond  the  vulva. 


SIMPLK    VAf;i.\AI.    IIVSTKRECTOMY 


325 


Fig.  ii^. — Vaginal  Hysterectomy. 


The  uterus  is  then  pulled  over  to  one  side  and  the  broad  ligament  of  the  one  side  including 
the  tube  and  the  ligamentum  ovarii  and  the  round  ligament  is  tied  off  by  three  heavy  chromic  or 
silk  sutures.  The  first  one,  nearer  the  cornu,  includes  one-third  of  the  broad  ligament;  the  second 
passes  one-half  inch  further  out,  includes  two-thirds  of  the  broad  ligament,  and  the  third  suture, 
passed  as  above,  includes  the  entire  broad  ligaments  above  the  uterine  artery.  In  passing  this 
third  suture  the  left  index  finger  is  passed  either  over  the  broad  ligament,  or  under  the  broad 
broad  ligament,  to  make  sure  that  no  other  structure  than  the  broad  ligament  is  included. 


SI.MIM.K    XAC.INAI.    H VSTERIX'TOMY 


327 


Fig.  114. — ^\'agixal  Hysterectomy. 


The  broad  ligament  ligated  with  these  three  silk  or  chromic  sutures  is  now  cut  through  with 
the  scissors,  the  line  of  incision  passing  close  to  lateral  wall  of  the  uterus. 


SIMPLK    VACINAI.    1 1  VS  ri;R  l'.(  TOiMY 


329 


Fig.  115. — ^\'aginal  Hysterectomy. 

As  the  scissors  cut  deeper,  it  is  wise  to  pass  the  left  index  finger  over  the  posterior  wall  of  the 
uterus  and  out  under  the  lower  part  of  the  broad  ligament  so  that  no  other  structures  than  the 
broad  ligament  will  be  cut. 


SlMI'l. 


XAC.IXAI,    IINSTIIRIXTOMV 


33^ 


Fig.  ii6. — Vaginal  Hysterectomy. 


The  uterus  is  then  delivered  outside  of  the  vulva  and  still  remains  attached  by  the  uncut 
upper  part  of  the  broad  ligament  of  the  other  side.  This  is  then  ligated  by  three  chromic  or 
silk  sutures  in  the  same  fashion  as  in  figure  113.  The  uterus  is  then  separated  from  this  broad 
ligament  in  the  manner  as  in  figure  114  and  the  hysterectomy  is  completed. 


SIMI'I.i;    \'A(;iXAL   ]IVSTKRECTOMY 


333 


Fig.  117. — ^Vaginal  HysterectOxMy. 


The  upper  chromic  or  silk  ligatures  of  either  side  are  used  to  pull  the  broad  ligament  stumps 
into  view  and  spongeholders  are  passed  between  them  into  the  peritoneal  cavity  to  dry  the  field  of 
operation  and  to  locate  any  possible  bleeding.  Two  clamps  are  uniting  the  peritoneum  of 
Douglas  to  the  post-vaginal  wall  at  its  highest  point,  having  be^n  applied  early  in  the  operation 
(Fig.  99).     External  to  them  are  seen  the  ligatures  about  the  uterine  arteries. 


SIMIMJ':    VA(;iNAI.    IINSTKRI'XTOMY 


335 


Fig.   ii8.^\"aginal  Hysterectomy. 


The  stumps  are  then  attached  to  the  antero-lateral  vaginal  walls;  No.  3  chromic  suture  is 
used.  The  suture  passes  through  the  lateral  margin  of  one  vaginal  flap  i  1/2  inches  below  the 
upper  angle,  then  through  the  ligamentum  ovarii,  then  through  the  united  peritoneum  and  pos- 
terior vaginal  edge  close  to  the  clamp  which  holds  tlie  peritoneum  and  vaginal  edge  together. 


SIMIMJO    VA(;iNAl,    lIVS'ri'lRl'.C'lO.MY 


337 


Fig.  119.- — ^Vaginal  Hysterectomy. 


The  stump  and  vaginal  flap  are  then  pulled  toward  the  median  line  and  the  suture  is  passed 
through  the  lateral  vaginal  flap,  preferably  near  the  area  which  constituted  the  uncut  bridge  of 
figure  loi,  but  above  the  ligature  passed  in  either  figure  104-105,  or  in  figure  loS. 


SIMIM.l-;    VACINAL    1 1 VSTIIR  ICCTOM  V  339 

Uv(\  firniU-  we'll  ahox'f  llic  vml  of  the  stump.  As  a  iTsull,  the  c-ntire 
thick  u|)|)cT  portion  of  the  broad  li,u;anu'nt  is  attached  closely  to 
anterodateral,  lateral  and  posterolateral  \'aginal  walls,  and  is  held 
outside  of  the  ])eritoneal  cavity  (Fi.i^  120).  The  same  ]jrocedure  is 
then  carried  out  on  the  other  side.  The  iodoform  strip  is  drawn  out 
and  the  operation  is  completed  in  one  of  two  ways. 

( I .)  By  the  first  method  peritoneal  surfaces  arc  united  and  the  edges 
of  the  vaginal  incision  likewise  between  the  exposed  stumps  of  the  broad 
ligaments  and  no  packing  is  introduced  into  the  pelvis.  This  procedure 
is  readily  accomplished  by  grasping  hold  of  the  peritoneum  reflected 
from  the  posterior  surface  of  the  bladder  and  uniting  it  by  continued 
or  interrupted  suture  to  the  peritoneum  forming  the  posterior  wall  of 
the  cul  de  sac  of  Douglas  wdiich  w^as  united  earlier  in  the  opera- 
tion (see  Fig.  117)  to  the  posterior  vaginal  incision  by  two  clamps. 
Then  the  vaginal  mucosa  is  united  in  the  same  fashion,  leaving  the 
stumps  projecting  in  the  vagina,  and  the  vagina  is  then  packed  with 
gauze.  If  by  any  chance  oozing  takes  place,  it  finds  its  outlet  through 
the  vagina,  unless  the  uterine  artery  by  some  chance  has  retracted 
and  is  the  cause  of  the  bleeding.  There  is  more  or  less  oozing  during 
the  operation,  the  bleeding  points  being  located  on  the  edge  of  the 
posterior  vaginal  incision,  especially  at  its  lateral  borders  and  along 
the  connective  tissue  lying  between  this  and  the  peritoneum. 

The  disadvantage  of  this  method  of  closure  is  that  the  bladder, 
through  the  peritoneum  over  its  posterior  surface,  is  held  close  to  the 
vaginal  wound  and  directly  over  the  apex  of  the  new  fornix.  Bleed- 
ing, if  it  should  occur  from  a  retracted  uterine  artery,  would  not  be 
recognized  early,  if  at  all.  The  new  cul  de  sac  of  Douglas  is  situated 
directly  over  the  peritoneo-vaginal  wound. 

(2.)  By  the  second  method  a  long  iodoform  strip  is  introduced  into 
the  peritoneal  cavity.  Over  the  lower  end  of  this  strip  which  projects 
into  the  vagina,  the  five  ligatures  of  either  side  are  tied  across  in  a 
double  knot  and  serve  to  keep  this  gauze  in  place  and  prevent  its 


340  VAGINAL   CELIOTOMY 

slipping  out  into  the  vaginal  canal  (Fig.  121).  The  vaginal  canal  is 
then  packed  with  a  wide  strip  of  iodoform  gauze,  the  bladder  emptied 
to  make  sure  that  the  urine  is  clear,  and  the  operation  is  completed. 

The  operation,  when  done  leisurely,  rarely  takes  more  than  forty 
minutes,  and  the  patient  suffers  scarcely  any  postoperative  annoyance- 
Owing  to  the  pressure  of  vaginal  gauze  on  the  urethra,  it  is  advisable 
for  the  first  few  days  to  catheterize  the  patient.  On  the  fifth  day  after 
the  operation  removal  of  the  vaginal  gauze  is  begun.  The  sutures 
which  are  tied  over  the  intraperitoneal  strip  of  gauze  are  no  obstacle, 
and  from  this  day  on,  four  to  six  inches  of  the  wide  intraperitoneal 
strip  of  iodoform  gauze  are  drawn  out  daily.  Finally,  after  removal  of 
the  gauze,  the  vaginal  fornix  shows  a  cone-shaped  denuded  area  con- 
taining the  stumps  of  the  broad  ligaments.  Daily  vaginal  douches 
are  then  given,  and  in  the  course  of  another  week  or  ten  days  com- 
plete healing  and  retraction  has  taken  place  in  many  cases. 

The  value  of  packing  iodoform  gauze  into  the  peritoneal  cavity 
instead  of  closing  up  the  edges  of  the  vaginal  incision  is  that  because 
of  the  introduced  gauze  an  exudation  of  lymph  is  thrown  out,  which 
eventually  forms  an  artificial  cul  de  sac  of  Douglas  situated  several 
inches  higher  than  the  normal  one.  It  also  prevents  the  intestine  by 
any  chance  becoming  adherent  to  the  vaginal  wound.  In  addition  to 
these  advantages,  it  diminishes  the  risk  of  the  subsequent  occurrence 
of  a  descent  of  the  vagina,  bladder,  rectum,  or  the  intestine.  The 
purpose  of  sewing  the  lateral  stumps  of  the  broad  ligament  so  firmly 
to  the  lateral  borders  of  the  vagina  is  that  in  the  course  of  subsequent 
retraction  of  these  stumps  the  lateral  vaginal  walls  and  bladder  are 
pulled  upward  and  the  occurrence  of  a  cystocele  or  descent  of  the 
intestine  or  a  prolapse  of  the  vaginal  walls  is  reduced  to  a  minimum. 

Use  of  Silk. — A  good  method  involves  the  use  of  silk  ligatures 
only,  instead  of  chromic,  and  the  introduction  of  iodoform  gauze 
into  the  pelvic  cavity.  In  tying  the  ligatures  about  the  lower  and 
upper  areas  of  the  broad  ligament  much  force  is  expended  and  chromic 


SIMPLE   VAGINAL  HYSTERECTOMY 


341 


Fig.  120. — X'agixal  Hysterectomy. 


The  chromic  suture  is  then  tied  after  the  other  ligatures  on  the  broad  ligament  stumps  have 
been  pulled  down  so  that  when  the  chromic  suture  is  tied  it  is  firmly  closed  above  all  other  sutures. 
The  clamp  which  holds  the  peritoneum  and  the  posterior  vaginal  edge  together  has  been  mean- 
while removed.  The  same  procedure  is  repeated  on  the  other  side.  We  now  have  the  broad  liga- 
ment slumps  in  the  vagina  and  practically  extraperitoneal. 


SIMIM.I';    VA(;i\AI.    IIYSTKRFXTOMY 


343 


Fig.  121. — ^\^AGINAL  Hysterecto-my. 
It  is  now  possible  to  complete  the  operation  by  any  one  of  the  several  methods,  the  peritoneum 
and  posterior  vaginal  edge  may  be  united  to  the  peritoneum  and  vaginal  wall  anteriorly  by  one  or 
more  interrupted  sutures  which  close  the  opening  into  the  peritoneum  and  leave  the  stumps  of 
the  two  sides  exposed  in  the  vagina.  I  prefer  to  introduce  a  long  wide  strip  of  iodoform  gauze  into 
the  peritoneal  cavity  which  pushes  the  intestines  up  and  holds  the  bladder  out  of  the  way.  The 
ligatures  of  the  two  stumps  are  then  tied  loosely  over  the  protruding  end  of  this  strip  of  iodoform 
gauze  and  then  the  chromic  sutures  which  united  the  stumps  to  the  antero-Iateral  vaginal  wall  are  cut. 
The  vagina  is  then  packed  with  another  strip  of  iodoform  gauze  which  may  be  removed  on  the  fifth 
day;  on  the  sixth  or  seventh  day  we  begin  to  draw  out  the  intraperitoneal  strip  of  gauze,  four  or 
five  inches  being  taken  out  on  each  successive  day  until  the  whole  strip  is  removed.  Douches 
are  then  given  twice  daily.  In  the  course  of  a  few  d^ys  the  silk  sutures,  if  silk  has  been  used, 
are  removed  by  scissors  or  else  they  are  pulled  out,  for  these  slough  away  and  with  them  the 
exposed  areas  of  the  broad  ligament  stumps.  .After  complete  removal  of  the  iodoform  gauze 
the  vault  of  the  vagina  usually  heals  without  further  attention.  In  some  cases  the  granulating 
forni.x  is  treated  with  pyroligneous  acid  or  silver  until  complete  healing  takes  place. 


SIMPLE   VAGINAL  HVSTKRIXTO.M  V  345 

sutures  readily  l^rcak.  The  c'.\]3()se(l  stumps  of  the  broad  ligament 
whicli  ]jroject  into  the  \'a,sj;ina  on  tlie  use  (^f  these  chromic  sutures  are 
not  always  (juickly  healed,  but  at  times  remain  as  granulating  points 
which  re(|uire  treatment.  With  the  use  of  silk  sutures  all  the  tissue 
below  them  sloughs  away,  so  that  no  projecting  ends  are  left  in  the 
vagina  after  the  twelfth  to  fifteenth  day.  The  disagreeable  feature 
connected  with  the  use  of  silk  ligatures  is  this  very  sloughing,  for  it 
produces  from  the  seventh  to  twelfth  day  (and  sometimes  longer)  an 
exceedingly  disagreeable,  malodorous  discharge,  which,  however,  has 
no  other  unpleasant  consequence  to  the  patient.  From  the  twelfth  to 
fourteenth  day  traction  on  the  silk  sutures  brings  them  away  or  they 
may  be  subsequently  cut  close  to  their  point  of  application  and 
removed. 


DISEASE  OF  THE  ADNEXA. 

In  diseases  and  pathological  conditions  of  the  tubes  and  ovaries 
the  choice  between  abdominal  and  vaginal  routes,  for  conservative 
or  radical  operation  on  the  adnexa,  must  take  into  consideration  the 
size  and  location  of  the  tumors,  the  element  of  adhesions,  the  necessity 
for  haste  and  the  question  of  mortahty  and  advantages.  Abel,  com- 
paring the  mortality  of  abdominal  and  vaginal  operations  for  inflam- 
mations of  the  adnexa,  explains  some  of  the  deaths  by  the  abdominal 
method  by  saying  that  the  operations  were  performed  early  in  his 
experience  and  that  some  of  them  were  cases  which  should  not  have 
been  operated  so  early.  Today  he  probably  uses  better  judgment 
in  selecting  the  time  for  operation  and  says  that  vaginal  operations  are 
less  dangerous  than  abdominal. 

A  comparison  of  the  cases  operated  by  him  abdominally  and  vagi- 
nally shows  this  difference:  out  of  sixty-five  inflammatory  cases,  53 
were  instances  of  pyosalpinx ;  four  of  ovarian  abscess ;  eight  were  tubo- 
ovarian  tumors  or  salpingo-oophoritis.  Six  died.  By  the  vaginal  route 
he  operated  on  thirty-three  cases  of  inflammatory  tumors  of  the  adnexa 
without  removal  of  the  uterus,  and  on  thirty-one  cases  of  inflammatory 
tumors  of  the  adnexa  with  the  removal  of  the  uterus,  with  two  deaths. 
A  study  of  the  thirty-three  cases  of  inflammatory  tumors  without  re- 
moval of  the  uterus  shows  that  only  nine  were  pyosalpinx,  nine  were 
tubo-ovarian  tumors,  six  cases  of  salpingo-oophoritis,  three  cases  of 
hematosalpinx,  and  one  case  of  hydrosalpinx.  These  certainly  rep- 
resent a  much  less  severe  form  of  disease  than  those  operated  by 
the  abdominal  route.  In  the  more  severe  cases  of  inflammatory 
diseased  adnexa  (thirty-one  in  number),  the  uterus  was  removed,  a 
step  of  great  advantage.     His  statistics  concerning  vaginal  operations 

346 


DISEASE    OF    THE    ADNEXA  347 

include  forlv-lwo  cases  of  rclroJlcxion  of  the  uterus  with  ikj  mortality, 
ten  cases  of  o\'arian  tumors,  one  ecto])ic  gestaticjn,  four  liysterectomies 
for  prolapse  of  the  uterus,  and  sixty- four  cases  of  inllamed  adnexa, 
«4i\-in<2;  him  the  very  l(j\v  mortality  of  1.66  per  cent,  for  121  operations, 
as  comj)are(l  with  a  mortality  of  6.6  per  cent,  for  i  21  abdominal  (Opera- 
tions including  sixty-four  inllammatory  cases.  Not  only  were  the 
reported  abdominal  operations  done  early  in  his  surgical  experience, 
but  they  were  of  a  much  more  severe  nature  than  those  done  vagin- 
ally, and  among  them  were  cases  operated  on  during  the  stage  of 
acute  inflammation,  cases  which  his  more  mature  experience  would 
lead  him  to  operate  radically  at  a  much  later  and  safer  period.  When 
we  take  into  consideration  that  the  vaginal  operations  include  forty- 
two  cases  of  retroflexion,  that  the  inflammatory  tumors  of  the  adnexa 
were  not  of  severe  grade,  that  the  severe  cases  of  pyosalpinx  gave 
a  much  better  prognosis  because  the  uterus  was  also  removed,  we  see 
how  unfair  the  comparison  is.  As  mentioned  elsewhere,  Schauta,  in 
sixty  vaginal  complicated  ovariotomies,  had  a  mortality  of  5  per  cent., 
whereas  in  forty-one  cases  of  uncomplicated  unilateral  vaginal  ovari- 
otomy his  mortality  was  nil. 

Diihrssen,  in  the  publication  of  his  first  500  cases  of  vaginal  celi- 
otomy, reported  fifteen  deaths:  a  mortahty  of  3  per  cent.  It  must  be 
mentioned,  however,  that  400  of  these  cases  represented  the  operation 
of  vaginal  fixation,  among  which  in  only  eighty  cases  one  or  both 
tubes  or  ovaries  w^re  removed.  Of  these  eighty  cases  only  eight  were 
pyosalpinx,  five  were  ectopics,  the  rest  were  cystic  ovaries,  hydrosal- 
pinx, oophoritis,  perisalpingitis,  and  hematosalpinx.  Of  these  400 
cases  six  died :  1.5  percent.  Seventy-three  operations  were  performed 
for  diseased  adnexa,  cases  of  a  more  severe  nature,  with  the  uterus 
anteflexed:  of  these  five  died.  Among  all  his  cases,  in  thirtv-three 
instances,  he  enucleated  myomata  from  the  uterus.  The  two  deaths 
among  these  thirty-three  were  due  to  operations  on  the  adnexa.  Thir- 
teen cases  of  ectopic  gestation  showed  one  death.     In  addition,  sixteen 


348  VAGINAL   CELIOTOMY 

cases  were  begun  vaginally  which  had  to  be  completed  by  a  vaginal 
hysterectomy  or  by  an  abdominal  laparotomy,  with  two  deaths.  If 
we  exclude  the  400  cases  of  vaginal  fixation,  the  vast  majority  of  which, 
320,  Avere  done  primarily  for  retroflexion  alone,  we  have  104  cases 
with  eight  deaths.  It  can  therefore  be  seen  that  the  severity  of  these 
cases  and  the  manner  in  which  the  statistics  are  compiled  hav^e  a  decided 
bearing  on  the  reported  mortality. 

INDICATIONS  AND  LIMITATIONS  IN  DISEASES  OF  THE  ADNEXA. 

In  fixing  for  oneself  the  indications  and  limitations  for  the  more 
extended  practice  of  vaginal  celiotomy,  it  is  necessary  to  make  a  com- 
parison between  the  relative  advantages  and  disadvantages  of  vaginal 
celiotomy  as  compared  with  abdominal  laparotomy.  The  vaginal 
operation  is  more  difficult,  takes  longer,  but  there  is  less  danger  from 
air  infection.  The  vagina,  for  practical  purposes,  can  be  rendered  as 
sterile  as  the  abdominal  wall.  The  operation  through  the  vaginal 
vault  is  slower,  but  involves  no  manipulation  of  the  intestines  and,  in 
consequence,  decidedly  less  shock.  Though  intestine  and  omentum 
present  in  the  wound,  nevertheless,  by  lifting  the  table  or  by  the  use  of 
gauze  sponges,  they  can  be  kept  out  of  the  field  of  operation.  Deep 
adhesions  can  be  loosened  by  the  sense  of  touch,  but  denuded  areas 
of  pelvic  peritoneum  and  intestinal  peritoneum  cannot  be  observed. 
Vaginal  celiotomy  is  not  an  operation  performed  in  the  dark,  for  the 
uterus  is  to  be  brought  out  into  the  vagina  and  whatever  is  to  be  removed 
must  also  be  brought  into  the  vagina,  so  that  all  ligation  and  cutting 
are  accomplished  with  the  aid  of  sight.  If  pus  is  poured  out  in  the 
course  of  an  operation,  it  is  said  that  it  flows  out  more  readily  when  the 
vaginal  route  is  used  and  that  there  is  less  danger  of  infection.  Patients 
convalesce  quickly  after  a  vaginal  celiotomy.  They  do  not  worry 
about  a  scar;  there  is  no  danger  of  hernia.  Many  patients  yield  to  a 
vaginal  operation  who  would  absolutely  refuse  an  abdominal  incision. 

The  abdominal  operation  is  easier  and  can  be  more  quickly  per- 


DISEASE    OF    THE   ADNEXA  349 

formed.  Adhesions  of  the  intestine  and  (jmentum  may  be  freed 
with  the  aid  of  sight.  The  deeper  adhesions  of  the  adnexa,  of  the 
uterus  or  of  adherent,  tumors  must  of  course  Ije  freed  by  the  fingers 
alone,  but  e\-en  here  the  eye  enables  us  to  see  rough  denuded  areas  of 
the  peritoneum,  to  see  the  exit  of  pus,  and  to  note  the  character  of  the 
intestinal ivall  v'hen  freed  from  adhesions — a  point  of  greatest  importance. 
It  may  be  said  that,  with  proper  protection  of  the  intestines  by  the 
abdominal  route,  and  with  the  careful  use  of  sponges,  the  danger  of 
infection  in  these  cases  should  be  no  greater  than  when  operating 
through  the  vagina.  In  addition,  the  abdominal  route  enables  us  to 
observe  the  appendix  and  to  remove  it  when  affected  or  to  remove  it  as 
a  routine  procedure. 

Comparing,  then,  the  advantages  of  the  two  methods,  it  may  be 
said  that  hernia  after  an  abdominal  operation  is  certainly  a  possibility, 
even  though  it  happens  only  after  an  infection  of  the  wound,  a  disturb- 
ance which  may  occur  in  spite  of  the  greatest  care.  The  advantages 
of  the  vaginal  method  are  that  the  patients  suffer  less  from  shock, 
that  there  is  no  danger  of  hernia,  and  that  patients  will  consent  more 
readily  to  the  operation.  Other  things  being  equal,  these  advantages 
are  of  great  weight  and  will  hold  good  in  many  cases  of  salpingitis  and 
inflammation  of  the  adnexa,  especially  in  multiparas  in  whom  extreme 
'conservatism  may  not  be  required.  If  continued  observation  and 
the  leukocyte  count  justify  the  conclusion  that  the  tubal  contents  are  no 
longer  virulent,  then  the  operation  may  be  undertaken. 

The  vaginal  method  is  certainly  allowable  if  tactile  examination 
gives  distinct  evidence  which  excludes  adhesions  with  the  intestine. 
The  all-important  question  is  whether  the  vaginal  route  should  be 
chosen  in  cases  of  tumors  and  conditions  associated  with  marked 
adhesions,  and  whether  in  these  severe  cases  the  mortality  rate  is 
lower. 

For  me,  the  contraindication  is  furnished  by  adhesions.  If  the 
tube  or  o\'ary  or  the  uterus  be  fixed  we  never  know  the  extent  of  the 


35©  VAGINAL   CELIOTOMY 

adhesions.  Many  cases  present  an  unexpected  extent  of  union  of 
uterus  and  adnexa  to  sigmoid,  rectum,  etc.,  which  is  of  so  marked 
a  character  that  when  adhesions  are  separated  rough,  denuded 
areas  of  peritoneum  are  produced,  all  of  which  demand  and  should 
receive  surgical  correction,  which  is  impossible  through  the  vagina. 

These  are  the  questions  which  are  of  importance  from  the  surgical 
standpoint.  Since  no  statistics  properly  compiled  definitely  prove 
the  vaginal  method  by  theory  or  results  to  give  a  markedly  better 
mortality  in  severe  cases  (except,  perhaps,  hysterectomy),  the  adop- 
tion of  this  method  for  extended  practice  depends  on  individual  reason 
and  experience.  Diihrssen  fixed  certain  contraindications,  and  today 
uses  the  vaginal  method  for  80  per  cent,  of  his  cases,  but  a  large  pro- 
portion of  these  are  uterine  displacements.  For  Schauta,  many 
of  these  contraindications  have  no  weight.  He  says,  as  quoted  above, 
"It  is  natural  that  every  operator  should  begin  with  laparotomy  and 
then  adopt  the  vaginal  mode  of  operation." 

For  Abel,  as  is  seen,  there  are  few  contraindications,  yet  here  is 
a  man  who,  after  practising  the  abdominal  method,  goes  over  to  the 
vaginal  procedure  and  uses  it  almost  exclusively.  Statistics  of  opera- 
tions by  the  vaginal  method  when  viewed  in  gross  are  better,  because 
very  many  cases  are  included  which  are  done  by  some  by  the  Alexander- 
Adams  operation  or  which  are  not  considered  sufficiently  severe  by 
others  to  justify  an  abdominal  operation.  The  vaginal  method  is 
often   practised  in  patients  who  would  refuse  an  abdominal  incision. 

TECHNIC. 

When  the  uterus  has  been  drawn  into  the  vagina  the  space  left 
between  its  posterior  wall  and  the  anterior  speculum  which  holds 
the  bladder  up  is  a  very  roomy  one,  provided  the  longitudinal  incision 
into  the  vesico-uterine  fold  (if  such  has  been  made)  has  been  a  long 
one,  and  provided  the  speculum  is  fairly  wide.  It  is  frequently  neces- 
sary to  have  the  aid  of  sponges  or  holders  to  keep  the  intestine  and 


DISKASK    OF    TIIK    ADXF.XA  35 1 


omentum  back,  which  process  is  made  easier  by  a  slight  ele\ation  of 
the  lower  end  of  the  operating  table.  These  small  gauze  sponges 
are  introduced  in  the  median  line  and  are  then  ])assed  laterally  to 
a  position  behind  and  external  to  the  tube  and  ovary.  With  the 
aid  of  such  sponges  on  long  si)ongeh(jlders  nonadherent  tubes  ancl 
oN'aries  can  be  rolled  and  drawn  into  the  vagina.  'J'he  fingers  ma\' 
then  be  introduced  through  this  space,  may  palpate  the  tubes  and 
ovaries,  bring  them  further  into  view,  loosen  cobweb  adhesions,  and 
draw  out  small  cysts  or  tumors  or  enucleate  adherent  tumors  or  pus 
sacs. 

It  is  evident  that  a  long  longitudinal  incision  in  the  anterior  vaginal 
wall  and  a  thorough  separation  of  the  bladder,  especially  at  the  lateral 
attachments  to  the  cervix,  a  long  incision  into  the  vesico-uterine  perit- 
oneum, and  the  introduction  into  the  peritoneal  cavity  of  a  wide 
speculum,  are  important  factors  in  bringing  the  adnexa  readily  into 
the  vagina.  With  a  large  uterus  or  if  the  uterus  grows  larger  after 
delivery  on  account  of  congestion,  which  usually  occurs,  the  space 
above  the  uterus  can  be  made  more  roomy  by  taking  out  the  posterior 
speculum  and  either  pulling  or  pushing  the  fundus  down  toward  the 
perineum.  If  the  uterus  is  rotated  so  that  one  horn  lies  anteriorly 
and  one  posteriorly,  the  adnexa  are  more  clearly  seen  and  the  entire 
width  of  the  broad  ligaments,  the  round  ligaments,  and  the  liga- 
mentum  ovarii  are  open  to  examination  or  operative  procedures. 

If  adhesions  are  present  these  must  first  be  loosened.  With  mild 
adhesions  of  cobwxb  type,  with  a  freely  movable  uterus,  the  delivery 
of  the  adnexa  is  a  simple  matter.  After  the  uterus  is  in  the  vagina 
gauze  sponges  or  the  introduced  fingers  readily  separate  such  loose 
stretchable  bands. 

If  more  firm  adhesions  are  present  two  fingers  are  introduced 
o\'er  the  fundus  along  the  posterior  wall  of  the  broad  ligament,  and 
the  tubes  and  ovaries  are  freed  from  their  adhesions  by  the  same 
manipulations    as    are    required    in    abdominal    operations.     If    the 


352  VAGINAL   CELIOTOMY 

Uterus  is  adherent,  of  course  it  must  first  be  loosened,  for  on  the 
thorough  dehvery  of  the  uterus  into  the  vagina  depends  the  ease  of 
dehvery  of  the  adnexa.  If  peritoneal  adhesions  hold  the  posterior 
wall  of  the  uterus,  these  may,  as  a  rule,  be  separated  with  the  aid  of 
the  eye  if  the  uterus  is  brought  well  forward.  Sometimes  it  is  neces- 
sary to  twist  the  uterus  around  so  that  our  horn  lies  anteriorly  and 
in  the  middle  fine.  This  brings  the  adherent  bands  and  the  adnexa 
more  readily  into  the  field  of  operation. 

If  extraction  of  the  corpus  is  difficult  through  peritoneal  adhesions, 
fixation  of  adnexa,  or  very  short  upper  hgamentum  latum  or  sclerosed 
ligamentum  infundibulo-pelvicum,  it  may  be  necessary  to  pull  first 
one  and  then  the  other  cornu  into  the  opening,  ligate  the  isthmus 
tubce  and  the  upper  part  of  the  ligamenum  latum.  This  allows 
the  fundus  to  pass  into  the  vagina  and  out  beyond  the  vulva,  and 
then  with  other  ligatures  and  clamps  the  adnexa  may  be  brought 
into  the  vagina.  This  manipulation  is  not  easy  in  nulhparae.  Some- 
times it  is  helpful  to  pass  narrow  side  retractors  into  the  peritoneal 
cavity,  which  exposes  a  much  deeper  area  of  the  broad  ligament 
and  permits  of  more  thorough  ligation  along  the  lateral  wall  of  the 
uterus.  Even  then  it  may  be  necessary  to  take  out  all  the  retractors 
and  specula  and  enter  with  two  fingers  of  one  hand  to  loosen  adhe- 
sions about  the  tube  ana  ovary.  If  we  take  out  all  the  specula  and  pull 
the  fundus  down  toward  the  rectum,  the  two  fingers  which  loosen 
the  adnexa  have  more  room  to  pass  along  the  posterior  wall  of  the 
ligamentum  latum. 

With  this  manipulation  it  is  often  of  great  advantage  to  use  the 
external  hand  as  in  a  bimanual  examination.  Care  is  necessary 
to  avoid  tearing  the  broad  ligament,  or  the  mesosalpinx  or  the  liga- 
mentum infundibulo-pelvicum,  all  of  which  are  frequently  thickened, 
brittle  or  sclerosed.     They  retract  and  bleed  freely. 

The  most  difiicult  operation  through  the  vagina  is  the  removal 
of  adherent   adnexa.     The  peritoneal   cavity    must   be   entered,  the 


DISEASE    OF    THE  ADNEXA 


353 


Fig.  122. — In  removing  inflamed  or  involved  adnexa  it  is  advisable  to  deliver  the  uterus  and 
then  to  separate  the  tube  and  ovary  from  adhesions.  Ligation  is  carried  out  by  mattress  sutures 
applied  from  the  cornu  of  the  uterus  through  the  mesosalpinx  and  meso-ovarium  out  to,  and 
including,  the  ligamentum  infundibulo-pelvicum,  or  in  the  reverse  order.  Whenever  possible, 
one  or  two  sutures  should  be  applied  to  the  ligamentum  infundibulo-pehicum  before  any  cutting  is 
done.     In  the  above  drawing  the  mattress  sutures  are  shown  a  little  too  far  apart. 


DISEASE    OF    THE   ADNEXA 


355 


Fig.  123. — If  it  is  not  possible  to  remove  the  adnexa  by  first  passing  mattress  sutures  from 
the  cornu  out  to  and  including  the  ligamentum  infundibulo-pelvicum,  ligation  and  cutting  are 
begun  at  the  cornu  of  the  uterus,  passing  in  this  way  out  to  the  ligamentum  infundibulo-peMcum. 
Great  care  is  necessary  that  the  outer  area  of  mesosalpinx  and  the  ligamentum  infundibulo-pel- 
vicum are  thoroughly  ligated  and  that  the  tissues  in  this  area  do  not  tear  and  shp  away  from  the 
control  of  the  operator.  The  area  of  the  entrance  of  the  tube  into  the  uterus  shows  the  wedge- 
shaped  excision  of  the  tubal  mucosa  to  be  closed  by  mattress  sutures. 


DISEASE    OF    THE   ADNEXA  357 

adiu'xa  nuist  Ijc  loosened  and  with  the  ukTus  brou^L^ht  into  the  vagina. 
Ligatures  are  then  apph'ed  and  the  achiexa  remcjved.  It  is  almost 
essential  to  get  the  uterus  into  the  vagina.  We  may  then  pull  hard 
on  the  uterus,  and  by  pulling  either  to  right  or  left,  or  by  rotating  the 
uterus  get  the  loosened  adnexa  of  the  one  or  other  side  nearer  to  the 
median  line  and  thus  make  it  possible  to  ligate  the  tube  and  ovary 
enucleated  with  the  introduced  finger  or  fingers.  If  these  tubes  and 
ovaries  are  not  readily  drawn  into  viev^  by  the  uterus,  delivery  may 
be  accomplished  by  the  aid  of  Cleveland  forceps  applied  to  the  tube 
or  ligamentum  ovarii.  Sometimes  it  is  necessary  to  put  clamps  on 
in  succession  and  thus  bring  the  tube  or  ovary  out.  Sometimes  it 
is  essential  to  put  a  ligature  about  the  tube  near  the  uterine  end,  and 
in  this  way  gradually  pull  the  outer  end  within  reach  of  the  fingers. 
Often  it  is  necessary  to  grasp  the  tube  near  the  uterine  end  with  a 
forceps  and  then  enter  the  peritoneal  cavity  with  the  fingers.  It 
is  often  impossible  by  these  manipulations  to  deliver  in  a  thorough 
surgical  manner  closely  adherent  tubes  and  ovaries,  especially  if 
they  are  situated  far  over  toward  the  lateral  wall  of  the  pelvis  or  if 
they  have  taken  on  a  pseudo-intraligamentous  growth. 

After  the  tube  and  ovary  are  loosened  from  their  adhesions,  gauze 
is  introduced  to  catch  any  pus  which  may  be  expelled.  If  contents 
of  the  tube  are  serous  or  catarrhal,  the  tube  may  be  washed  out  with 
salt  solution.  If  the  outer  end  of  the  tube  is  closed  a  new  ostium 
is  made;  this  method  of  opening  and  forming  a  new  ostium  gives  the 
opportunity  for  complete  restoration  that  makes  pregnancy  possible. 
If  the  contents  are  of  a  suspicious  nature  the  tube  is  excised  after 
the  adnexa  of  the  other  side  are  examined.  If  the  ovary  is  normal, 
only  the  tube  is  removed.  If  the  uterine  end  appears  involved  this 
is  excised  out  of  the  uterine  horn,  and  bleeding  points  must  be  caught 
and  ligated.  Frequently,  after  getting  the  adnexa  loose,  we  have 
little  room  for  exsection.  Safety  demands  that  ligatures  be  tied 
about  the  outer  end  of  the  broad  ligaments,  around  the  hgamentum 


358  VAGINAL   CELIOTOMY 

infundibulo-pelvicum  and  then  at  the  uterine  end  of  the  tube.  Mattress 
sutures  are  then  appHed  to  the  intervening  area  (Fig.  122).  If  it 
be  impossible  to  reach  the  infundibulo-pelvic  hgament  first,  we  must 
begin  at  the  uterine  end  and  work  outward  with  mattress  sutures, 
but  the  outer  part  containing  the  ovarian  artery  must  not  be  allowed 
to  tear  or  slip  while  tying  these  last  and  most  important  sutures  about 
the  ovarian  artery  (Fig.  123).  If  it  is  purposed  to  remove  the  adnexa 
of  both  sides,  then  the  uterus  should  also  be  removed.  The  opera- 
tion should  then  consist  of  a  vaginal  hysterectomy  with  median  split- 
ting of  the  uterus. 

ECTOPIC  GESTATION. 

The  vaginal  operation  for  ectopic  gestation  in  the  early  months 
is  the  same  as  for  inflammatory  adnexa.  The  structures  must  be 
handled  gently  so  that  the  ligamentum  infundibulo-pelvicum  does 
not  tear.  There  is  httle  shock  and  a  thorough  removal  of  the  blood 
is  permitted. 

With  small  ectopic  tumors  an  operation  through  the  vagina  is  pre- 
ferred by  Diihrssen,  Martin,  and  Abel.  With  this  method  it  is  easy 
in  favorable  cases  to  remove  an  ovum  not  yet  expelled  from  the  tube. 
The  uterus  is  brought  out  and  the  tubes  become  visible  and  may  be 
reached  by  the  fingers;  the  corresponding  ovary  with  the  tube  is 
loosened  from  its  adhesions  and  is  brought  out  into  the  field  of  opera- 
tion. If  the  tube  is  intact  it  is  split,  the  egg  is  removed  and  the  opening 
is  closed,  so  that  the  lumen  is  preserved  (Martin).  If  the  tube  cannot  be 
preserved,  it  is  removed  by  tying  the  mesosalpinx  in  small  sections; 
the  end  remaining  near  the  cornu  is  left  open  if  the  mucous  membrane 
looks  normal.  This  retained  part  of  the  tube  is  split  and  the  mucous 
membrane  around  the  incision  is  united  with  the  serosa  to  form  an 
artificial  opening.  If  blood  has  accumulated  in  the  recto-uterine 
space,  it  is  removed  by  sponges,  the  peritoneal  wounds  are  closed, 
uterus  is  replaced  and  the  vaginal  incisions  are  sewed.     If  the  hemato- 


OVARIAN    CYSTS  359 

cele  Ijchind  llic  uterus  is  lart^c,  a  poslcric^r  vaginal  incision  is  made  and 
the  blood  is  removed.  If  an  hematocele  is  encapsulated  in  its  up]jer 
area  this  protecting  wall  is  not  to  be  broken  through.  Jt  is,  however, 
necessary  to  get  the  tube  out  of  the  hematocele  into  view.  If  this  is 
not  in  good  condition,  it  should  be  removed.  All  oozing  must  be 
stopped.  If  the  peritoneum  is  infiltrated  with  blood,  if  there  is  paren- 
chymatous hemorrhage,  the  space  should  be  filled  with  sterile  gauze, 
and  bleeding  points  in  the  edge  of  the  vaginal  incision  should  be 
caught  and  ligated. 

Personally  I  believe  all  ectopic  gestations,  except  old  hematoceles 
which  may  be  drained  per  vaginam,  should  be  approached  by  the 
abdominal  route,  except  such  early  cases  as  are  not  definitely  diag- 
nosed, as  have  no  bleeding  through  tubal  abortion  or  tubal  rupture, 
and  such  as  are  operated  on  vaginally  for  diagnostic  reasons  and  are 
then  completed  vaginally  because  of  ease  of  execution. 

OVARIAN   CYSTS. 

Schauta  early  adopted  the  method  of  vaginal  celiotomy  for  the 
performance  of  ovariotomy.  He  was  the  first  to  use  the  vaginal  route 
for  the  removal  of  large  cystic  tumors  of  the  adnexa,  cysts  containing 
from  ten  to  fifteen  quarts  of  fluid.  He  said  that  ovariotomy  is  easily 
done  through  the  vagina  if  the  cyst  is  movable  and  pedunculated.  Even 
if  only  a  small  part  of  the  cyst  surface  can  be  reached,  it  can  readily 
be  punctured  by  a  trocar.  The  cyst  wall  thus  opened  is  pulled  through 
the  vaginal  incision,  the  pedicle  is  tied  and  the  cyst  removed.  There 
is  room  enough  for  this  procedure  even  in  large  cysts  in  which  the  lower 
pole  of  the  tumor  does  not  dip  down  into  the  pelvis.  In  that  event, 
the  lower  pole  can  be  reached  through  the  peritoneal  incision  by  in- 
troducing two  fingers  into  the  peritoneal  cavity  along  which  the  trocar 
can  be  pushed  into  the  cyst,  which  may  then  be  drawn  down  after 
being  emptied.  Schauta  in  his  operations  removes  dermoid  and  also 
multilocular  cysts,  one  cyst  after  another  is  emptied  by  the  trocar  so 


360  VAGINAL   CELIOTOMY 

that  unilocular  cysts  are  not  the  only  ones  adapted  to  this  method. 
The  great  claim  made  for  the  vaginal  method  is  that  it  is  less  danger- 
ous and  that  the  statistics  as  regards  mortality  are  better.  It  is  a 
question  whether  this  claim  can  be  substantiated  to  the  degree  claimed 
by  its  adherents. 

According  to  Burger,  the  rate  of  mortality  for  abdominal  ovari- 
otomy varies  between  4  and  10  per  cent.,  though  Pean  reports  mortality 
of  only  2  per  cent.  Burger  reported  from  the  Clinic  of  Schauta  a 
mortality  of  9.55  per  cent,  in  394  ovariotomies.  Of  the  thirty-two 
deaths  Burger  takes  out  twenty-three,  which  he  says  are  not  in  direct 
and  immediate  connection  with  the  operation,  making  the  mortality 
figured  on  this  basis  2.68  per  cent.  Abel,  in  reviewing  these  statistics, 
says  that  instead  of  nine  deaths  twenty-two  are  in  direct  connection 
with  the  operation.  He  finds  among  the  cases  excluded  by  Burger 
five  cases  of  sepsis  in  which  bacteria  were  present  before  the  opera- 
tion, one  case  of  pneumonia,  one  case  of  pneumonia  after  a  second 
operation  for  intestinal  obstruction,  one  pneumonia  after  a  case  of 
carcinoma,  one  pneumonia  following  a  twisted  pedicle  operation, 
one  pneumonia  after  a  purulent  cyst,  one  gangrene  of  the  lung  follow- 
ing operation  for  twisted  pedicle;  three  deaths  from  weak  heart  and 
fatty  heart,  two  deaths  from  emboli  of  the  lung,  one  death  from  intesti- 
nal obstruction  and  hydronephrosis  due  to  ligating  a  ureter.  Abel 
says  that  Biirger's  report  shows  the  abdominal  operation  to  be 
dangerous  through  sepsis,  ileus,  heart  collapse,  lung  affections,  emboli, 
and  internal  hemorrhage.  Since  he  considers  many  lung  complica- 
tions, emboli,  and  ileus  due  to  intestinal  paralysis,  as  evidence  of 
sepsis,  he  finds  that  abdominal  operations  are  not  free  from  danger. 
It  can  thus  be  seen  how  differently  statistics  are  reviewed  according 
to  the  bias  of  the  observer. 

That  the  character  of  the  cases  operated  on  is  of  vast  importance 
is  shown  by  the  fact  that  Schauta  in  sixty  complicated  vaginal  ovari- 
otomies was  compelled  in  nineteen  cases  to  remove  the  uterus.     His 


OVARIAN    CYSTS  36 1 

mortality  was  5  j)er  cent.  In  forty-one  unconiplicatcd  vaginal  ovari- 
otomies his  mortality  was  nil. 

Abel  believes  that  all  ovarian  tumors  should  be  removed  tlirough 
the  vagina,  except  very  large  cystic  tumors,  large  solid  tumors,  and 
carcinomatous  tumors  of  the  ovary.  Intraligamentous  tumors  and 
tumors  with  twisted  pedicles,  which  Burger  says  should  be  done 
through  the  abdomen,  Abel  does  through  the  vagina.  For  Abel, 
adhesions  are  no  contraindications.  They  must  be  extremely  exten- 
sive, he  says,  to  furnish  an  obstacle  which  cannot  be  overcome  by  the 
vaginal  route.  Size  is  no  obstacle  so  long  as  the  tumors  are  cystic, 
says  Abel.  He  finds  the  removal  of  small  cystic  tumors  to  be  with- 
out danger.  The  vaginal  operation  for  larger  and  complicated  cystic 
tumors  is  less  dangerous  and  the  same  holds  good  in  the  case  of  dermoid 
cysts.  He  advises  the  abdominal  method  only  for  exceptionally 
large  cystic  tumors,  for  large  solid  tumors,  and  for  carcinomatous 
growths  of  the  ovary. 

The  vaginal  route  is  to  be  preferred  in  multiparae  if  the  cystic 
tumors  are  not  large,  especially  if  they  are  movable  and  if  there  are 
no  adhesions.  Even  large  cysts  extending  above  the  pelvic  brim 
may  be  speedily  removed  in  this  manner.  After  opening  the  perit- 
oneum, if  the  tumor  does  not  present  it  may  be  pushed  dowm  by 
pressing  through  the  abdomen,  or  by  grasping  the  pedicle,  or  by  grasp- 
ing the  tumor  itself.  With  the  latter  method  it  is  better  to  first  intro- 
duce gauze  so  that  the  peritoneum  is  protected.  I  use  the  vaginal 
method  if  the  fluid  tumors  are  not  adherent,  and  if  the  uterus  is 
movable,  so  that  it  may  be  delivered  into  the  vagina.  If  the  uterus 
is  extracted  by  the  anterior  route  we  have  a  roomy  opening,  and  by 
pulling  on  the  ligamentum  ovarii  we  may  bring  the  lower  pole  of 
the  tumor  into  the  field.  This  method  works  well  with  small  tumors, 
but  it  is  not  wise  to  use  it  if  the  pedicle  be  twisted,  if  the  tumors  be 
dermoids,  or  if  the  tumors  be  solid. 

With  the  anterior  vaginal  incision,  even  if  the  uterus  cannot  be 


362  VAGINAL   CELIOTOMY 

delivered,  if  the  lower  pole  is  brought  into  the  field,  the  cyst  may  be 
punctured  with  a  trocar.  In  the  case  of  small  movable  cysts  removal 
is  then  a  ready  procedure.  With  adherent  cysts  puncture  by  trocar 
or  dressing  forceps  brings  part  of  the  cyst  wall  into  the  field  of  opera- 
tion and  makes  its  entrance  into  the  vagina  possible,  after  which 
deeper  adhesions  are  loosened,  some  with  the  fingers  and  others  with 
the  aid  of  sight.  Leaking  which  may  take  place  in  the  peritoneal 
cavity  is  not  always  thoroughly  removed  unless  we  also  make  a 
posterior  incision. 

I  use  the  posterior  vaginal  method  for  small  tumors  which  lie 
deep  behind  the  uterus  and  can  be  felt  by  the  internal  examining 
fingers,  or  if  they  lie  directly  on  the  posterior  fornix.  If  the  tumor 
lies  behind  the  uterus  the  posterior  incision  is  made.  If  the  tumor 
ruptures  it  drains  well  through  the  posterior  incision. 


HYSTERECTOMY  (Continued). 

In  doing  vaginal  hysterectomy  we  must  avoid  the  occurrence  of 
cystocclc  after  taking  out  the  uterus.  Hysterectomy  may  be  per- 
formed for  prolapse,  and  certainly  in  that  event  we  must  do  something 
to  prevent  the  bladder  and  vagina  from  subsequently  coming  down . 
Here  the  value  of  the  inverted  J_ -incision  with  thorough  separation  of 
the  bladder  becomes  apparent.  To  prevent  the  descent  of  the  bladder 
it  must  first  have  been  separated  from  all  surrounding  structures  and 
then  a  special  attachment  of  the  flaps  should  be  made  to  the  broad 
ligament  stumps.  Either  the  wound  is  closed  between  the  stumps  by 
union  of  peritoneal  surfaces  and  union  of  vaginal  edges,  or  at  com- 
pletion of  operation  the  incision  is  not  closed  and  the  lower  pelvis 
is  packed  with  gauze.  These  methods  lift  or  push  a  completely 
separated  bladder  up  and  retain  it  back  of  the  symphysis,  so  that  the 
risk  of  its  subsequent  descent  is  reduced  to  a  minimum.  For  complete 
prolapse  of  the  uterus,  however,  hysterectomy  is  most  unreliable. 
The  only  way  to  make  certain  that  the  bladder  will  never  again  descend 
is  to  fix  the  uterus  in  front  of  it. 

In  many  cases,  except  large  fibroid  uteri,  anterior  vaginal  celiotomy 
with  the  inverted  _L -incision  and  thorough  separation  of  the  bladder 
from  its  uterovaginal  connections  makes  vaginal  hysterectomy  an  op- 
eration of  simplicity  and  ease,  for  at  no  step  are  we  working  in  the 
dark.  Every  bit  of  tissue  which  is  tied  and  cut  is  clearly  exposed 
to  the  eye.  The  bladder  and  ureters  are  removed  from  points  of 
danger  and  the  shock,  annoyance,  and  fear  associated  with  abdominal 
operations  are  obviated. 

Hysterectomy  includes  the  removal  of  the  uterus  alone  without  the 
adnexa,  or  first  the  uterus  and  then  the  adnexa,  or  removal  of  the 
uterus  plus  the  attached  adnexa.    The  important  points  in  the  removal 


3^3 


364  VAGINAL   CELIOTOMY 

of  the  uterus  are:  the  avoidance  of  injury  to  the  bladder,  ureters  or 
rectum,  and  the  thorough  tying  of  the  uterine  and  ovarian  arteries, 
more  especially  the  uterine  arteries,  for  these  are  so  situated  that  they 
readily  retract,  and  that  part  of  the  broad  ligament  in  which  they 
run  is  not  easily  grasped  and  pulled  into  view.  In  the  tying  of  the 
ovarian  arteries,  however,  when  the  uterus  alone  is  to  be  rem.oved,  we 
have  the  long  and  easily  manipulated  upper  area  of  the  broad  ligament 
with  the  tube  and  hgamentum  ovarii  as  points  easy  to  hold  and  tie, 
and  if  the  uterus  plus  the  adnexa  are  to  be  removed,  traction  on  the 
broad  ligament  after  preliminary  removal  of  the  uterus  or  traction  on 
the  uterine  horns  still  attached  to  the  tubes  and  ligamentum  ovarii, 
especially  so  if  the  uterus  has  been  split,  enables  us  to  pull  the  liga- 
mentum infundibulum  pelvicum  and  its  contained  ovarian  artery  into 
the  field  of  operation. 

A  factor  which  renders  vaginal  hysterectomy  difficult  is  the  inability 
in  many  cases  to  pull  the  cervix  well  down  toward  the  vulva.  This  is 
due  to  the  existence  of  short,  inelastic  or  sclerosed  ligaments  around 
the  cervix,  more  especially  the  ligamenta  cardinalia,  to  perimetritis,  or 
to  adherent  adnexa,  or  to  irregular  fibroid  tumors  of  the  uterus. 

This  immobility  renders  approach  to  the  lower  area  of  the  uterus 
and  to  the  uterine  arteries  somewhat  difficult,  and  usually  renders 
the  delivery  of  even  a  small  fundus  into  the  vagina  not  easy  of  accom- 
plishment. Mobility  of  the  uterus  is  readily  increased  if  the  cervix 
and  the  lower  part  of  the  uterus  are  freed  from  all  their  surrounding 
attachments,  more  especially  so  from  the  ligamenta  cardinalia;  hence 
it  is  advisable  in  practically  all  cases  to  begin  the  operation  by  a  thor- 
ough separation  from  below.  This  includes  the  separation  of  the 
bladder  anteriorly,  separation  and  penetration  into  the  cul  de  sac  of 
Douglas  posteriorly,  and  a  separation  of  the  lower  part  of  the  broad 
ligament  laterally,  up  to  and  including  the  uterine  arteries  (Fig.  108). 
Thorough  separation  of  the  bladder  and  tying  of  the  uterine  arter- 
ies, if  done  at  this  stage,  aids  not  only  to  avoid  injury  to  the  ureters,  but 


H  YST  !■;  R  i:CTOMY  365 

the  most  iinnoyin*;-  c()ni])licati(jn  in  the  operation,  bleeding  from  the 
uterine  arteries,  is  oljviated.  Therefore,  whether  hgation  be  done 
from  below  u[)\var(l,  or  from  above  downward,  or  by  a  combination 
of  the  two  methods,  whether  this  is  done  by  ligatures  or  clamps,  with 
hemisection  or  with  splitting  of  the  uterus  or  not,  by  morcellement 
or  not,  preliminary  ligation  of  the  ligamenta  cardinalia  and  of  the 
uterine  arteries  should  always  be  carried  out  whenever  possible. 

In  many  instances  the  simple  act  of  separation  of  the  bladder 
from  the  cervix  and  uterus  causes  oozing.  The  separation  of  the 
bladder  from  the  anterior  fornix  and  anterior  vaginal  wall  has  the 
same  effect.  Any  vaginal  hysterectomy  done  with  preliminary  en- 
trance into  the  cul  de  sac  of  Douglas  has  likewise  this  troublesome 
feature.  The  most  annoying  oozing  occurs  when  the  posterior 
fornix  is  incised  and  the  tissue  lying  between  the  incision  and  the 
cul  de  sac  of  Douglas  is  penetrated;  here  the  oozing  continues  almost 
incessantly,  especially  at  the  extreme  lateral  edges  of  the  incision. 
This  may  be  controlled  by  clamps  which  unite  the  peritoneum  and 
vaginal  edge  at  the  ends  of  the  vaginal  incision,  or  by  union  of  these 
tissues  by  interrupted  sutures  or  by  the  use  of  mattress  sutures.  These 
procedures  are  sometimes  necessary,  but  they  take  time  and  occasion- 
ally limit  the  space  through  which  we  are  compelled  to  work.  The 
higher  up  the  posterior  fornix,  that  is,  the  further  from  the  external 
OS  the  transverse  incision  is  made  for  the  purpose  of  entering  the  cul 
de  sac  of  Douglas,  the  less  is  the  oozing. 

After  preliminary  separation  of  the  cervix  and  lower  uterus  from 
its  surroundings  and  after  ligation  of  the  uterine  arteries,  the  upper 
part  of  the  uterus  and  broad  ligament  still  remain  to  be  considered. 
If  the  uterus  can  then  be  delivered  into  the  vagina  it  may  be  removed 
with  or  without  its  adnexa  by  ligation  from  above  downward,  or  by 
the  application  of  clamps  from  above  downward.  If  it  is  impossible 
to  deliver  the  uterus,  because  it  is  held  back  too  firmly  by  sclerosing 
broad  ligaments,  or  by  adherent  adnexa,  the  upper  part  of  the  broad 


366  VAGINAL   CELIOTOMY 

ligament  may  be  treated  by  ligation  from  below  upward,  or  by  the 
application  of  clamps  from  below  upward,  or  the  anterior  wall  of 
the  uterus  may  be  split  or  the  uterus  may  be  split  completely  into 
halves,  and  these  when  drawn  out  give  us  a  point  from  which  we  may 
pull  out  or  enucleate  the  adnexa,  and  in  that  way  ligate  or  clamp 
off  the  broad  ligaments  from  above  downward.  If  the  uterus  is  too 
large  to  be  dehvered,  even  with  hemisection  or  splitting,  as  is  the  case 
in  fibroids  of  the  uterus,  sphtting  of  the  lower  part  is  carried  up  as 
high  as  possible  and  then  either  myomata  are  enucleated  m  toto  or 
else  from  the  median  line  outward  as  much  as  needed  is  cut  out  of 
the  tumor  tissue ;  nothing  of  the  uterus  tissue  being  cut  out,  only  many 
smaller  or  larger  bits  of  fibromatous  tissue,  until  the  uterus  is  so 
diminished  in  size  that  it  may  then  be  delivered  into  the  vagina,  with 
of  without  complete  hemisection  or  complete  splitting.  Then,  the 
upper  part  of  the  broad  ligament  may  be  treated  with  ligatures  or 
clamps. 

There  are  cases  where,  on  account  of  the  brittleness  of  the  tissue, 
or  because  of  free,  constant  oozing,  or  because  of  the  desire  for  haste, 
or  because  of  the  inaccessibihty  of  the  lower  part  of  the  broad  liga- 
ment, the  treatment  of  the  ligamenta  cardinalia  and  of  the  uterine 
arteries  must  be  carried  out  by  the  use  of  clamps  or  by  ligation  from 
above  downward.  Usually  one  or  two  good  heavy  clamps  on  either 
side  suffice.  This  much  is  certain,  that  so  soon  as  the  hgamenta 
cardinalia  are  thoroughly  tied  or  clamped,  and  then  cut  from  the 
uterus,  the  mobihty  of  this  organ  is  increased.  There  are  cases  where 
after  this  preliminary  separation  of  the  cervix  and  the  lower  segment 
of  the  uterus,  this  part  of  the  uterus  is  entirely  cut  off  in  order  to 
obtain  a  more  ready  approach  to  the  remaining  part  of  the  uterus. 
This  is  the  case  in  fibroids  of  irregular  outline,  where  it  is  desirable 
to  approach  the  full  width  of  the  tumor  for  the  purpose  of  carrying 
out  enucleation  or  morcellement,  especially  submucous  or  interstitial 
tumors. 


hystI':rectomy 


367 


Fig.  124. — Semidiagrammalic  drawing  showing  the  operation  of  hemisection,  i.e.,  splitting 
the  anterior  wall  of  the  cervix  and  uterus  to  any  desired  height  up  to  and  beyond  the  fundus, 
by  separating  the  bladder,  incising  the  peritoneum,  introducing  anterior  retractor  into  the  perit- 
oneal cavity  and  grasping  the  highest  points  of  the  incision  in  the  split  uterus  as  we  pass  from 
below  upward. 


HYSTERECTOMY 


369 


Fig.  125. — Semidiagrammatic  drawing  of  the  method  of  hemisection,  i.e.,  splitting  the 
anterior  wall,  of  a  large  uterus  in  order  to  aid  delivery  of  the  fundus.  Drawing  shows  only  the 
anterior  wall  split,  it  shows  the  location  of  the  successive  applied  volsella. 


24 


HYSTICRIX'TOMV 


371 


Fig.  126. — The  First  Step  in  Bisection,  i.e.,  the  Complete  Splitting  of  the  UterI'S. 

After  the  cervix  has  been  released  from  its  attachment  to  the  ligamenta  cardinalia,  after  the 
bladder  has  been  separated  in  front,  after  the  cul  de  sac  of  Douglas  has  been  entered  posteriorly, 
volsellum  forceps  are  applied  to  the  lateral  walls  of  the  cervix  and  the  organ  is  split  in  the  median 
line  with  a  pair  of  scissors. 


HYSTKRKCTOMY 


373 


Fig.  127. — After  the  splitting  is  continued  upon  the  anterior  and  posterior  walls  for  a  certain 
distance  (about  2  inches)  two  pairs  of  volsella  are  applied  to  either  side  of  the  split  area  of  the 
anterior  wall  of  the  cervix.  Tension  is  exerted  on  these.  The  anterior  retractor  is  pushed  up 
still  further  and  the  splitting  is  continued  in  the  median  line  up  toward  the  peritoneal  plica. 


TnsTi:Ri;(:TOMY 


375 


Fig.  128. — As  the  splitting  is  extended  higher  up,  the  vesico-uterine  fold  of  perineum  is 
reached  and  if  this  has  riot  been  incised  before,  it  is  now  split  in  a  transverse  direction  and  the 
anterior  speculum  is  introduced  into  the  peritoneal  cavity.  Successive  volsella  are  appUed  higher 
until  the  fundus  is  drawn  out.  By  oversight,  the  incision  in  the  posterior  wall  of  the  cervix  is 
not  shown. 


HYSTERECTOMY 


377 


Fig.  129. — In  pulling  out  the  fundus,  the  manipulation  is  aided  by  the  act  of  pushing  the 
cervix  back  into  the  upper  part  of  the  vagina.  The  splitting  is  simply  continued  through  the 
fundus  and  down  the  posterior  wall. 


hysti:ri:ct(jmy 


379 


Fig.  1,-jo. — After  the  fundus  has  been  delivered  the  cervix,  if  possible,  is  again  pulled  down; 
the  index  finger  of  the  left  hand  is  introduced  back  of  the  uterus,  behind  the  bridge  still  uniting 
the  two  halves,  and  on  the  palmar  surface  of  this  finger  a  pair  of  scissors  cuts  upward  and  bisects 
the  uterus  into  two  complete  halves.  This  latter  manipulation  of  the  finger  protects  the  omentum 
and  intestine  from  injury. 


HYSTERECTOMY  38 1 

Splittinii;  of  the  iilerus  is  cither  incfjmplcte  and  confined  to  the  one 
wall,  usually  the  anterior,  and  is  then  known  as  hemisection  (Figs. 
124,  125),  or  as  complete,  the  uterus  being  divided  entirely  into  two 
halves  (Figs.  126--130).  Neither  of  these  procedures  is  a  difficult  one, 
unless  the  adhesions  to  the  posterior  wall  of  the  uterus  are  exceedingly 
dense;  or  unless  the  presence  of  pyosalpinges  makes  opening  of  the 
anterior  cul  de  sac  somewhat  difficult;  or  unless  there  are  fibroids  in 
the  uterus  which  must  be  enucleated  or  removed  by  morcellement  be- 
fore the  hemisection  or  complete  splitting  can  be  carried  out.  After 
the  uterus  is  split  into  two  complete  halves  and  delivered,  we  have,  by 
pushing  one  half  back  into  the  peritoneal  cavity,  abundant  room  for 
carrying  out  the  desired  manipulation  on  the  broad  ligament  or  adnexa 
of  the  one  half  remaining  outside  the  vulva.  We  are  able  to  pull  on 
the  uterus,  to  bring  the  ligamentum  infundibulo-pelvicum  nearer  into 
the  field;  we  are  able  to  pass  along  the  posterior  wall  of  the  broad 
ligament  and  enucleate  the  adherent  tubes  and  ovaries ;  we  have  a  bet- 
ter view  of  the  intestinal  adhesions  to  the  inflamed  adnexa.  In  those 
cases  where  the  uterine  arteries  have  not  been  tied  early  in  the  opera- 
tion, complete  splitting  enables  us,  by  ligating  from  above  downward, 
to  find  these  vessels  in  such  a  position  that  the  ureter  is  in  little  or  no 
danger. 

~  Splitting  of  the  uterus  is  always  advisable  if  delivery  of  the  fundus 
is  difficult  because  of  short  broad  ligaments  or  adherent  adnexa; 
if  the  uterus  is  large;  if  the  uterus  contains  fibroids;  if  we  are  dealing 
with  a  double  pyosalpinx  and  are  going  to  do  a  hysterectomy,  or  if 
the  clamps  are  to  be  used.  The  advantages  gained  by  sphtting  the 
uterus  in  case  of  fibroids  are :  that  it  makes  the  delivery  of  the  uterus 
easier ;  permits  of  making  the  uterus  smaller  by  enucleation  or  morcelle- 
ment of  tumors;  that  we  have  a  better  approach  to  the  upper  para- 
metrium and  the  adnexa,  and  that  it  makes  temporary  or  permanent 
clamping  safe,  since  it  is  done  outside  of  the  vulva  from  above  down- 
ward without  the  risk  of  injuring  the  intestines. 


T,82  VAGINAL   CELIOTOMY 

The  advantages  of  splitting  the  uterus  in  hysterectomy  for  double 
pyosalpinx  are:  to  loosen  it  and  the  broad  hgaments  from  adhesions, 
because  we  have  good  hold  on  either  half  of  the  uterus  for  exerting 
traction  on  the  adnexa;  that  each  half  with  its  connected  ligamentum 
latum  permits  exposure  of  the  posterior  wall  of  this  ligament  and 
allows  the  fingers  to  follow  it  or  slip  along  it  to  enucleate  pus  tubes  or 
ovaries.  The  posterior  wall  of  the  ligamentum  latum  is  the  important 
landmark. 

The  advantages  of  splitting  the  uterus  where  clamps  are  to  be 
used  temporarily  or  permanently  are :  that  it  enables  us  in  many  cases 
to  get  along  with  a  small  number  of  clamps  (Fig.  131);  that  they  can 
be  applied  from  above  downward  when  each  half  of  the  uterus  is 
outside  of  the  vulva;  that  they  can  thus  be  more  readily  clamped  ex- 
ternal to  tube  and  ovary;  that  injury  to  the  bladder  is  avoided  and 
intestine  is  out  of  the  way,  and  that  the  ends  of  the  clamps  can  be  seen 
(Fig.  132).  The  clamps  may  be  applied  entirely  from  above  down- 
ward, or  else  one  or  more  are  first  applied  to  the  lower  part  of  the 
broad  ligament  and  the  uterine  arteries,  and  then  one  or  more  from 
above  downward  after  delivery  of  the  hemisected  or  entirely  spht 
uterus. 

A  great  advantage  in  applying  one  or  more  clamps  to  the  broad 
ligament  from  below  upward  and  one  or  more  from  above  down- 
ward (Fig.  133)  is  that  the  handle  of  these  clamps,  after  the  two 
halves  of  the  uterus  with  the  adnexa  have  been  removed,  are  allowed 
to  sink  down.  This  doubles  the  broad  ligament  on  itself,  so  that  the 
points  of  the  clamps  applied  from  below  upward  and  the  ones  applied 
from  above  downward  are  close  together  parallel.  This  enables  us  to 
close  the  peritoneum  and  to  unite  the  edges  of  the  vaginal  incision  if 
desired  or  to  pack  the  lower  pelvis  with  gauze  and  still  have  the 
points  of  these  clamps  outside  of  the  peritoneum  in  the  vagina  and 
away  from  contact  with  the  bladder  and  intestine. 

So  far  as  the  use  of  clamps  is  concerned,  it  may  be  necessary  to 


HYSTKRKCTOMY 


583 


Fig.  131. — After  the  uterus  has  been  split  in  two,  each  half  in  turn  is  drawn  out  beyond 
the  vulva,  the  index  and  middle  fingers  of  the  left  hand  pass  over  the  broad  ligament  including  the 
Fallopian  tube  and  ovar\-  between  them,  and  then,  if  possible,  one  long  broad  ligament  clamp  is 
applied  from  above  downward  beginning  above  external  to  the  Fallopian  tube  at  the  ligamentum 
infundibulo-pelvicum  and  ending  below  ver}'  close  to  the  cervix  above  the  ligated  uterine  artery. 


HYSTERECTOMY 


385 


Fig.  132. — Semidiagrammatic  drawing  of  the  clamping  from  above  downward  of  the  bisected 
uterus  after  delivery  of  the  fundus.  On  the  right  side  of  the  drawing  the  clamps  are  applied 
just  e.xternal  to  the  uterine  horn  and  do  not  include  the  ovar}-  and  only  a  small  area  of 
the  tube.     On  the  left  side  of  the  drawing  they  are  applied  external  to  the  tube  and  ovary. 


HYSTIORI'.CTOMY 


587 


Fig.  133. — Semidiagrammatic  sketch  of  the  clamping  of  the  broad  ligament  of  the  delivered 
bisected  uterus  by  two  clamps  instead  of  one.  One  clamp  is  applied  from  below  upward  before 
delivery  of  the  split  uterus.  The  clamp  appUed  to  the  upper  half  of  the  broad  ligament  is  then 
allowed  to  drop  down  so  that  it  hes  parallel  to  the  clamp  applied  from  below,  the  broad  ligament 
in  this  way  being  doubled  upon  itself  and  the  tips  of  the  clamps  being  protected  so  that  they  do 
not  by  any  possibility  press  upon  the  bladder  or  any  intra-abdominal  structures. 


ii\s'I'i;kI':ctomy 


389 


Fig.  134. — Semidiagrammatic  drawing  of  the  clamping  of  the  uterus  without  splitting,  the 
clamping  being  entirely  done  from  below  upward.  On  the  right  side  the  clamping  is  done  close 
to  the  uterus  and  does  not  include  the  tube  and  ovary.  On  the  left  side  it  includes  the  tube  and 
ovary  running  out  into  the  ligamenta  infundibulo-pelvicum.  The  last  apphed  clamp  to  the  upper 
part  of  the  broad  ligament  must  receive  the  utmost  care  to  avoid  catching  omentum  and  intestine. 


HYSTERECTOMY  39 1 

open  the  peritoneum  anteriorly  and  posteriorly,  to  put  on  the  clamps 
from  Ijelow  upward,  to  cut  between  the  clamp  and  the  cervix  and 
uterus  after  each  clamp  is  applied,  and  thus  put  the  clamps  on  in 
succession  while  passing  upward  to  the  top.  This  method  may  be 
used  where  great  haste  is  necessary,  where  it  is  not  desirable  to  deliver 
the  fundus,  or  to  split  the  uterus  partially  or  completely.  This  may 
be  the  case  where  rapid  work  is  required  for  the  removal  of  the 
uterus  to  stop  uncontrollable  hemorrhage  or  where  a  septic  uterus  or 
ruptured  uterus  is  removed  (Fig.  134). 

As  a  rule,  it  is  advisable  to  deliver  the  uterus  anteriorly  and  then 
clamp  the  ligaments  in  ioto,  or  in  part,  from  above,  or  from  above 
and  below.  If  the  uterus  is  not  too  large  and  if  the  broad  ligaments 
are  not  too  thick,  one  should  try  to  get  the  whole  ligament  with  one 
clamp  (Fig.  131),  using  a  second  if  one  does  not  suffice.  If  it  is  not 
possible  at  first  to  deliver  the  uterus,  we  should  tie  the  uterine  artery 
from  below^  and  then  separate  the  lower  part  of  the  parametrium  from 
the  cervix  and  uterus,  and  should  then  attempt  to  deliver  the  fundus 
either  through  the  cul  de  sac  of  Douglas  or  anteriorly.  If  this  is  not 
possible,  the  uterus  should  be  split  or  made  smaller,  either  by  splitting 
the  anterior  wall  alone  as  it  is  brought  down  by  successively  applied 
volsella  or  else,  as  described  above,  by  complete  sphtting  of  the 
uterus  according  to  the  method  of  ^liiller. 


MYOMECTOMY. 

Myomectomy  is  the  term  used  to  define  the  removal  of  fibro- 
myomatous  tumor  or  tumors  from  the  uterus  by  enucleation  or  by 
morcellement  with  retention  of  the  uterus  and  the  sewing  of  the  bed 
of  the  enucleated  tumor  in  layers.  Myomectomy  is  also  part  of  the 
operation  of  hysteromyomectomy,  in  which  the  tumor  or  tumors  are 
removed  by  enucleation  or  morcellement  with  the  direct  purpose  of 
so  diminishing  the  size  of  the  uterus  that  it  may  be  bisected,  delivered, 
and  removed. 

Cervical  myomata,  if  situated  on  the  anterior  wall  in  the  supra- 
vaginal area,  are  reached  by  a  transverse  incision  in  the  anterior 
fornix  associated  with  a  long  longitudinal  incision  and  followed  by 
upward  separation  of  the  bladder.  This  brings  the  tumor  within 
the  operative  field  of  vision  and  permits  of  its  removal  with  or  without 
thespHtting  of  the  cervix. 

If  situated  on  the  posterior  wall  of  the  cervix,  a  longitudinal  incision 
in  the  posterior  fornix  or  a  transverse  incision  or  a  combination  of 
the  two  permits  of  approach  to  the  fibroid  if  situated  beneath  the 
cul  de  sac  of  Douglas. 

For  fibromyomata  situated  above  the  plica  or  above  the  fold  of 
Douglas,  that  is,  intraperitoneal  fibroids,  the  peritoneal  cavity  must  be 
entered  from  below. 

The  performance  of  myomectomy  by  the  vaginal  route  depends 
much  on  the  size  and  form  of  the  uterus.  If  we  are  dealing  with  the 
capacious  vagina  and  fornix  of  a  multipara,  a  fairly  large-sized  uterus 
containing  one  or  more  myomata  may  be  brought  through  anterior 
celiotomy  before  the  vulva.  It  goes  without  saying  that  in  any 
such  instance  myomata,  whatever  their  position,  may  be  readily 
removed ;  if  situated  subperitoneally,  by  simply  incising  longitudinally 

392 


MYOMECTOMY  393 

or  Iranswrsc'h-  oxer  the  projcctin^L^  tumors  and  enucleating  them; 
if  interstitial,  by  same  form  of  iiH'ision,  the  enucleation,  however, 
extenchng  deeper  down  even  to  the  mucosa;  if  submucous,  the  myo- 
mata  may  Ije  removed  by  still  deeper  incision,  even  to  the  extent 
of  splitting  the  fundus  or  the  entire  anterior  uterine  wall. 

Even  though  the  uterus  be  movable  and  not  greatly  enlarged, 
irregular  iibromyomata,  particularly  those  attached  to  the  fundus 
and  to  anterior  wall  of  the  corpus,  may  render  extraction  of  the  uterus 
difficult,  because  the  tumors  impinge  above  the  anterior  speculum 
under  the  symphysis,  and  this  obstructs  their  delivery.  Pressure 
through  the  abdomen  may  be  of  aid  in  the  delivery  of  the  tumors 
and  the  uterus  in  such  cases. 

The  essential  point  is  to  manipulate  the  tumor  into  the  operative 
field,  either  by  delivering  the  uterus  into  the  vagina  or  by  so  manipu- 
lating the  uterus  that  the  tumor  comes  into  the  field  of  vision  and 
can  be  grasped. 

The  two  methods  include,  then,  the  delivery  of  the  uterus  with 
its  contained  myomata  and  the  delivery  of  the  uterus  after  remov- 
ino;  one  or  more  of  the  tumors.  When  the  uterus  cannot  be  delivered 
into  the  vagina,  the  operation  is  a  more  difhcult  procedure,  unless 
the  tumor  or  tumors  are  situated  in  the  lower  segment  of  the  uterus 
or  cervix  or  unless  the  tumors  can  be  projected  into  the  peritoneal 
opening,  enucleated,  and  then  the  uterus  delivered.  The  longer 
the  uterus  and  the  higher  the  tumor,  the  more  difiicult  it  is  to  reach 
the  fibroid. 

In  some  cases  it  is  necessary  to  hgate  and  cut  the  lower  part  of 
the  broad  ligaments,  often  including  the  uterine  arteries.  Cutting 
the  attachments  of  the  ligamenta  cardinalia  to  the  uterus  enables  us 
to  draw  the  uterus  down  and  brings  the  tumors  lying  higher  up  more 
readily  into  the  operative  field. 

If  situated  on  the  posterior  wall  of  the  uterus  and  not  too  large, 
the  peritoneal  cavity  is  entered  by  posterior  celiotomy,  the  cervix  is 


394  VAGINAL   CELIOTOMY 

pulled  upward  toward  the  urethra,  and  volsella  applied  in  succession, 
bringing  the  tumor  or  tumors  through  the  vagina  or  at  least  down 
into  the  field  of  vision. 

A  uterus  containing  one  or  more  large  fibromyomata  situated  in 
the  corpus,  making  the  uterus  too  large  to  permit  of  delivery  by  anterior 
or  posterior  methods,  may  be  reached  by  the  method  of  splitting 
the  cervix  anteriorly  (Fig.  135)  or  posteriorly  or  by  both  incisions, 
after  previously  entering  the  peritoneal  cavity  anteriorly  and  posteriorly. 
The  tumors  as  they  come  into  view  may  be  enucleated  in  Mo,  or  by 
excision  of  pieces  designed  to  so  diminish  them  in  size  that  the  beds 
in  which  they  lie  are  brought  more  closely  into  view.  Through  the 
splitting  of  the  anterior  wall  of  the  uterus  aided  by  tying  oS.  the  lower 
parametrium  high  lying  tumors  may  be  reached.  Then  it  is  hard 
to  know  if  the  remnant  of  the  uterus  is  worth  saving.  The  vaginal 
operation  is  not  so  bad  when  we  are  dealing  with  one  large  tumor, 
but  it  is  more  severe  if  we  are  dealing  with  several,  for  until  the 
delivery  of  uterus  into  the  vagina  it  is  not  possible  to  sew  up  the  base 
of  enucleated  myomata,  and  these  bases  continue  to  bleed  and  ooze 
after  the  uterus  is  replaced  until  this  is  done. 

With  the  uterus  extensively  filled  with  several  myomata,  especially 
such  as  are  deep,  there  is  often  no  value  in  attempting  to  retain  this 
organ  of  generation  as  a  useful  structure,  and  its  removal  is  then 
carried  out. 

PORTIO  MYOMATA. 

Split  the  capsule,  grasp  the  tumor,  enucleate  with  fingers,  scissors, 
or  knife. 

CERVICAL  INTERSTITIAL  MYOMATA. 

Separate  the  bladder.  If  the  tumor  is  lower  than  the  plica,  it 
is  not  necessary  to  open  the  plica.  If  the  tumor  is  higher  than  the 
plica,  the  peritoneum  must  be  opened,  the  capsule  of  the  tumor  is 


MVOMIXTOMY 


395 


Fig.'  135. — Splitting  of  the  anterior  wall  of  the  cervix  without  entering  the  peritoneal  cavity 
in  order  to  expose  the  inner  surface  of  the  lower  part  of  the  uterus  for  the  removal,  with  the  aid  of 
sight,  of  polypi,  etc.,  through  the  interna!  os.  If  the  peritoneum  is  entered  the  uterus  may  be  split 
up  to  the  fundus  for  the  same  purpose. 


MYOMECTOMY  397 

incised,  and  tht-  tumor  is  enucleated.  It  may  be  necessary  to  pass 
up  to  the  tumor  1)y  splitting  the  cervix. 

If  tile  myomata  are  very  large,  use  the  myoma  knife  of  Segond 
to  make  the  tumor  smaller  by  exsecting  pieces.  Then  the  tumor  may 
be  enucleated. 

If  the  cavity  of  the  uterus  is  entered,  one  should  be  careful  in  closing 
the  o])enings  and  cuts  to  have  no  knots  on  the  inner  surface  of  the 
uterus. 

SUBSEROUS  MYOMATA  IN  DOUGLAS. 

If  they  project  into  the  fornix,  they  may  be  attacked  from  beIov^\ 
If  the  tumor  is  on  the  posterior  wall,  it  may  be  necessary  to  enter  the 
peritoneal  cavity  and  then  grasp  the  cervix  or  corpus  and  enucleate. 
If  situated  deeper  in  the  wall,  it  may  be  necessary  to  split  the  posterior 
wall  of  the  cervix  up  to  the  tumor. 

CORPUS  PEDICLED  MYOMATA. 

If  not  in  the  cul  de  sac  of  Douglas  they  may  be  reached  by  an- 
terior celiotomy  and  are  to  be  removed  in  toto  or  by  morcellement. 

CORPUS  SUBSEROUS  MYOMATA. 

If  situated  above  the  plica,  are  to  be  reached  by  entering  the  perit- 
oneum. If  the  uterus  can  be  delivered  into  the  vagina,  the  fibroids 
may  be  readily  removed.  If  not,  the  tumor  itself  is  delivered  or 
else  the  tumor  is  removed  by  morcellement,  even  if  the  tumor  has  to 
be  reached  by  sphtting  the  uterus  from  the  cervix  up. 

SUBMUCOUS  AND  DEEP  INTERSTITIAL  TUMORS. 

These  are  reached  by  splitting  of  the  anterior  wall  of  the  cervix 
and  of  the  uterus  up  to  the  tumor.  If  necessary,  we  split  the  posterior 
wall  also,  even  if  the  peritoneum  there  is  also  opened. 

INTRALIGAMENTOUS  TUMORS. 

If  they  project  into  the  fornix  they  may  be  attacked  from  below. 
The  bladder  is  separated,  the  cervix  is  incised  on  the  affected  side, 


398  VAGINAL   CELIOTOMY 

and  the  ligamentum  cardinale  with  the  uterine  artery  is  tied  and 
cut,  and  we  then  pass  through  this  created  space  by  blunt  dissection 
up  to  the  tumor.  Approach  to  the  myomatous  areas  of  the  uterus 
is  rendered  more  easy  or  possible  if  we  first  ligate  and  then  cut  the 
cardinal  ligaments  and  the  uterine  arteries.  When  this  is  done, 
it  is  not  so  easy  to  save  the  uterus.  If  the  patient  is  young,  desires 
children,  and  sufficient  uterine  tissue  is  left  behind,  one  may  be 
conservative. 

VAGINAL  MYOMECTOMY  CONCLUSIONS. 

With  small  fibroids  the  size  of  the  fist,  especially  if  single,  vaginal 
hysterectomy  is  a  simple  operation. 

With  multiple  tumors,  there  is  the  risk  of  so  destroying  the  uterus 
as  to  leave  too  httle  normal  tissue  behind.  The  same  risk  occurs 
with  the  abdominal  method. 

A  few  safe  rules  with  all  vaginal  operations  on  myomata  follow: 
If  enough  of  the  tumor  is  cut  out,  the  remainder  of  the  tumor  with 
the  uterus  may  then  be  delivered  into  the  vagina.  Always  try  to  get 
the  tumor  into  the  field  of  vision  before  attempting  exsection.  Attempts 
at  enucleation  and  exsection  should  be  confined  to  the  tumor  mass 
itself. 

The  lateral  borders  of  the  uterus  should  be  avoided  in  delivering 
the  uterus  or  in  exsecting  pieces,  for  here  are  blood  vessels,  venous 
plexuses,  and  the  ureters.     Avoid  grasping  the  adnexa  or  pulling  them. 


HYSTEROMYOMECTOMY. 

In  cases  where  conservative  action  is  not  intended  and  where  hys- 
terectomy is  desired,  the  same  general  principles  of  enucleation  of  the 
tumors  and  delivery  of  the  uterus  hold  good  as  in  myomectomy. 

Successful  removal  of  the  myomatous  uterus  per  vaginam  depends, 
first,  on  the  ease  of  approach  to  the  tumor  and  the  size  of  the  vagina 
and,  second,  on  the  size  of  the  tumor  itself.  If  necessary,  Schuchard's 
incision  gives  easy  approach  to  the  fornix.  This  incision  begins  at 
the  border  of  the  middle  and  lower  third  of  the  left  side  of  the  introitus. 
The  incision  goes  externally  5  cm.  through  the  skin.  Internally,  the 
cut  goes  through  the  vaginal  wall  avoiding  the  rectum  and  passes 
through  the  fascia  and  the  musculature,  especially  the  levator  ani,  up  to 
the  fornix.  Spurting  vessels  are  caught,  but  the  bleeding  stops,  as  a 
rule,  through  the  pressure  of  the  introduced  posterior  speculum. 

The  abihty  to  diminish  the  size  of  the  tumor  with  the  aid  of  eye  and 
finger  make  size  no  obstacle,  so  that  it  is  not  so  much  the  size  of  the 
tumor  as  the  element  of  adhesion  to  surrounding  structures  which 
determines  the  value  or  success  of  the  vaginal  operation.  If  the  tumors 
are  not  too  large  and  if  there  are  not  many  adhesions,  the  vaginal  opera- 
tion may  be  indicated,  even  if  the  uterus  reaches  up  to  the  navel.  If 
the  tumors,  however,  are  very  large  or  incarcerated  or  if  there  be 
many  adhesions,  the  abdominal  route  is  indicated.  Either  the  rela- 
tively small  uterus  is  delivered  anteriorly  or  posteriorly,  after  pre- 
liminary ligation  of  the  ligamenta  cardinalia  and  the  uterine  arteries, 
or  else  the  uterus  is  made  smaller  by  enucleation,  evidement  or  mor- 
cellement,  so  that  finally  the  uterus  may  be  split  into  two  halves  and 
brought  out  before  the  vulva  and  removed. 

It  is  often  impossible  to  enter  the  peritoneal  cavity  anteriorly  or 
posteriorly  in  the  earliest  stage  of  the  operation.     After  separation  of 

399 


400  VAGINAL   CELIOTOMY 

the  bladder  the  anterior  cervix  wall  is  incised  longitudinally  as  far  as 
possible,  or  the  posterior  wall,  or  both.  Clamps  or  ligatures  are  ap- 
plied laterally  to  the  lower  parametriura  to  permit  the  uterus  when 
freed  here  to  be  pulled  down  so  that  the  body  of  the  uterus  is  within 
easy  reach,  after  which  the  anterior  and  posterior  peritoneum  is  opened. 
The  cervix  is  pulled  toward  the  urethra  when  the  tumor  is  in  the  pos- 
terior wall;  if  the  tumor  is  in  the  anterior  wall,  the  cervix  is  pulled 
down  toward  the  rectum.  The  uterine  wall  is  split  up  to  the  fibroid, 
the  capsule  is  spht  and  retracted  to  the  sides,  and  the  fibroid  is  taken  hold 
of  with  Muzeux.  The  tumor  is  enucleated  by  cutting  pieces  out  of  it, 
always  grasping  the  higher  areas  before  cutting  off  the  lower  pieces. 

Constant  attention  should  be  paid  to  the  bladder  and  the  rectum. 
The  area  to  be  excised  should  be  grasped  with  tenacula  and  cut.  Heavy 
tenacula  should  be  constantly  applied  to  pull  the  uterus  down.  After 
a  while  the  fibroid  is  enucleated  or  numerous  fibroids  are  removed,  so 
that  eventually  only  the  shell  of  the  uterus  is  left,  and  its  removal  is 
aided  by  complete  sphtting. 

In  general  it  is  advisable,  whenever  possible,  to  make  an  opening 
first  into  the  cul  de  sac  of  Douglas  by  a  transverse  incision  and  to  sepa- 
rate the  bladder  by  a  combined  transverse  and  longitudinal  fornix 
incision,  and  then  ligate  the  ligamenta  cardinalia  and  the  uterine 
arteries.  Then  the  cervix  is  split  anteriorly  and  posteriorly  and  vol- 
sella  are  applied  to  the  two  halves  of  the  cervix  until  the  lowest  pole 
of  the  tumor  is  brought  into  the  field  of  operation,  either  through  the 
anterior  or  through  the  posterior  incision,  and  the  tumor  mass  is 
grasped  by  volsella.  When  the  anterior  wall  of  the  uterus  is  split  and 
the  tenacula  are  put  on  higher  and  higher,  it  may  be  possible  to  pull 
the  fundus  uteri  so  far  forward  that  the  broad  ligaments  can  be  ligated 
from  above  downward.  If  this  is  not  possible,  the  anterior  wall  is 
made  smaller  through  central  exsection,  the  so-called  evidement  of 
Doyen  (Fig.  136),  so  that  the  fundus  may  finally  be  extracted.  Pieces 
are  cut  out  with  the  knife  of  Segond  or  with  curved  scissors.     The 


IIVSTKROMYOMECTOMY 


401 


Fig.  136. — Semidiagrammatic  drawing  of  the  process  known  as  central  evidement  in  the 
operation  of  hysteromyomectomy.  After  the  cervix  has  been  freed  from  its  attachment  to  the 
hgamenta  cardinalia,  separated  from  the  bladder  in  front,  after  the  cul  de  sac  of  Douglas  has  been 
entered  posteriorly,  the  cervix  is  grasped  latterly  by  two  heavy  volsella  and  two  diverging  incisions 
are  made  along  the  anterior  wall  of  the  uterus  through  the  fibroid  structures,  pieces  being  resected, 
as  shown  above,  from  the  central  area,  which  so  reduces  the  uterus  in  size  that  delivery  beyond  the 
vulva  is  possible. 


26 


i\s'i'i;k().\no.Mi;('io.\iv 


403 


Fig.  137. — Semidiagrammatic  drawing  of  the  process  known  as  morcellement  in  vaginal 
hysterorayomectomy.  After  the  cervix  has  been  ligated  from  the  hgamenta  cardinaUa  and  after 
the  bladder  has  been  separated  in  front  and  the  cul  de  sac  of  Douglas  entered  behind  (if  possible), 
the  cervix  is  grasped  by  a  heavy  volsella  and  by  transverse  incisions  the  cervix  is  cut  away  up  to 
the  highest  accessible  point  of  the  body  of  the  uterus,  after  which  an  incision  is  made  through  the 
anterior  wall  of  the  uterus  in  the  median  Une,  and  pieces  are  exsected  to  the  right  and  left  of  the 
median  line  until  the  uterus  is  reduced  in  size  sufficientlv  to  admit  of  deliverv  before  the  vulva. 


HYSTEROMYOMECTOMY  405 

next  area  of  tumor  or  uterus  is  always  firmly  grasped  with  a  volseJlum 
before  the  preceding  piece  is  completely  cut  off.  Either  we  continue 
this  original  splitting  in  the  median  line  and  proceed  to  exsect  pieces 
from  either  side  of  the  median  line  or  else  we  make  two  diverging 
incisions  with  resection  of  the  area  lying  between  them  (Fig.  136), 
exerting  constant  care  to  keep  the  bladder  out  of  the  field  of  operation 
and  with  constant  avoidance  of  the  lateral  margin  of  the  uterus  itself, 
so  that  we  may  not  increase  the  bleeding  or  grasp  or  tear  the  broad 
ligaments.  Sufiicient  space  is  finally  gained  to  enucleate  the  tumor  or 
tumors  and  eventually  to  leave  only  the  shell  of  the  uterus.  This 
organ  is  then  split  completely  into  two  halves  and  is  drawn  before  the 
vulva,  and  the  operation  is  then  to  be  completed  by  clamps  or  liga- 
tures. If  there  are  several  tumors,  these  are  attacked  in  succession 
until  the  uterus  is  small  enough  to  permit  of  ligation  of  the  broad 
ligaments  from  below  or  from  above.  If  this  method  is  not  pos- 
sible, the  method  of  morcellement  of  Pean  is  attempted  (Fig.  137). 

The  cutting  should  always  be  done  close  to  the  middle  line  to 
avoid  the  ureters  and  the  vessels.  The  uterine  arteries  should  be 
tied  or  clamped.  The  cervix  is  separated  bilaterally  from  the  lower 
parametrium  to  an  area  above  the  uterine  arteries.  By  transverse 
cuts,  the  anterior  and  posterior  walls  of  the  cervix  are  removed, 
always  grasping  an  area  above  the  place  being  exsected  before  this 
exsected  piece  is  entirely  cut  off.  After  removing  the  cervix  the  uterus 
is  attacked  by  bringing  it  down,  and  if  this  is  not  possible,  Ave  con- 
tinue cutting  pieces  away  from  the  center  and  thus  pass  upward  to 
the  peritoneum.  Central  exsection  is  continued  until  the  fundus  can 
be  pulled  down  and  the  ligaments  clamped,  which  latter  step  is  made 
easier  by  the  complete  splitting  of  the  uterus  after  which  the  clamps 
are  applied.  The  adnexa  may  be  clamped  later  or  together  with  the 
two  halves  of  the  uterus. 

Abel  says:  "He  who  can  control  the  vaginal  method  to  the  greatest 
possible  degree  can  by  morcellement  vaginally  remove  fibroid  tumors 


4o6  VAGINAL   CELIOTOMY 

which  are  scarcely  considered  possible.  It  is  not  right  to  say  that  only 
myomata  which  extend  to  the  umbilicus  should  be  attacked  vaginally 
and  that  larger  tumors  should  be  removed  abdominally.  This  depends 
on  the  size  of  the  vagina,  the  motility  of  the  tumor,  and  the  skill  of  the 
operator.  There  is  no  doubt  that  the  vaginal  operation,  even  if  it 
lasts  longer  because  of  a  protracted  morcellement,  constitutes  a  much 
less  dangerous  attack  than  the  abdominal  operation." 

In  case  of  large  Jibromyomata,  the  practice  of  morcellement  often  per- 
mits of  the  removal  of  extremely  large  fibroid  tumors  and  is  a  method 
which  can  often  be  used  to  advantage,  unless  we  are  dealing  with 
fibroids  which  are  particularly  intrahgamentous.  For  those  who 
practise  supravaginal  hysterectomy,  the  abdominal  route,  of  course, 
furnishes  a  ready  means  for  the  removal  of  large  fibroid  uteri.  I 
believe,  however,  that  the  removal  of  the  cervix  is  often  indicated  in 
these  cases.  Abdominal  hysterectomy  is  then  often  a  difficult  opera- 
tion. The  cervix  is  very  long  and  the  danger  of  injury  to  the  bladder, 
and  especially  to  the  ureters,  is  very  great.  For  that  reason,  in  doing 
a  complete  hysterectomy  in  the  severer  cases,  I  think  it  is  sometimes 
advisable  to  begin  the  operation  vaginally,  separating  the  bladder, 
opening  the  cul  de  sac  of  Douglas,  and  ligating  laterally  to  the  cervix, 
up  to  and  including  the  uterine  arteries.  The  remainder  of  the  opera- 
tion is  then  completed  with  much  greater  ease  through  the  abdomen. 
This  same  procedure  I  believe  to  be  the  ideal  one  in  early  operations 
for  carcinoma  of  the  fundus  uteri,  in  which  cases  infiltration  of  the 
ligamentum  cardinale  is  absent. 


VAGINAL  CESAREAN  SECTION. 

"Oljstc'trics  has  in  recent  years  followed  more  and  more  a  surgical 
direction.  Tn  ])lace  of  a  trusting  reliance  on  the  action  of  natural 
forces,  there  is  the  tendency  to  active  interference,  to  rapid  and  sure 
completion  of  the  complications  by  operative  measures.  We  no 
longer  care  to  watch  and  wait,  when  in  one  sitting  and  with  one  narcosis 
everything  can  be  rectified  in  the  manner  of  a  surgical  operation. 
This  is  proven  by  the  increasing  preference  for  active  measures  in 
abortus,  placentia  previa,  and  eclampsia ;  the  fondness  for  prophylactic 
version  in  narrow  pelvis  and  the  increase  in  Cesarean  sections  for  rela- 
tive indications;  above  ah,  however,  by  the  range  which  the  attempts 
toward  artifical  dilatation  or  widening  of  thecervix  have  taken  (Bumm)." 

For  those  cases  wdiere  a  rapid  emptying  of  the  uterus  was  necessary, 
with  the  entire  cervix  preserved,  Diihrssen  recommended  the  use  of 
the  metreurynter  and  made  this  method  popular  in  Germany. 

If  immediate  delivery  was  indicated,  through  danger  to  the  mother 
or  child,  Diihrssen  used  the  metreurynter  when  possible,  and  attempted 
to  draw  quickly  through  the  cervix  the  bag  filled  to  the  size  of  a 
child's  head. 

Cases  exist  where  with  "erhalten"  cervix,  howTver,  it  is  impossible 
to  introduce  the  intrauterine  bag  or  where  with  it  no  sufficient 
dilatation  results  or  where,  on  account  of  the  great  danger  to  the 
mother,  an  immediate  emptying  of  the  uterus  is  indicated.  If  it  is 
not  possible  in  these  cases  to  introduce  the  bag  through  the  cervix 
or  if  it  is  not  possible  to  pull  the  filled  metreurynter  through  the  cervix 
within  a  reasonable  time,  then  valuable  time  is  lost  when  the  cervix  is 
not  dilated  in  its  supravaginal  area. 

To  avoid  such  delay,  Diihrssen  advised  the  sjjlitting  of  the  entire 
cervix  and  of  the  lower  uterine  segment,  without  opening  the  perit- 

407 


4o8  VAGINAL   CELIOTOMY 

oneum,  without  greater  danger  of  bleeding,  and  obtained  in  that 
manner  an  opening  sufficiently  large  to  admit  of  extraction  of  a  ful- 
term  child  without  difficulty. 

In  the  development  of  these  ideas  he  was  assisted  by  the  experience 
gained  in  gynecological  operations  known  as  anterior  vaginal  celiotomy. 

In  order  to  permit  of  ready  version  and  of  ready  completion  of  the 
extraction  through  a  narrow  vagina,  a  perineo-vaginal  incision  may  be 
made  and  spurting  vessels  are  tied.  The  important  element  in  the 
vagino-perineal  incision  consists  in  cutting  not  only  the  vagina,  but 
the  levator  ani  and  the  constrictor  cunni.  The  cervix  is  then  brought 
into  view  by  introducing  two  large  specula  of  Doyen.  Two  lateral 
guiding  sutures  are  passed  through  the  cervix,  and  the  posterior  cervix 
is  split  longitudinally,  including  a  2  cm.  area  of  the  posterior  fornix. 
The  loose  connective  tissue  is  separated  from  the  posterior  uterine 
wall  by  means  of  the  finger  introduced  into  the  opened  fornix.  Then 
the  anterior  lip  of  the  cervix  is  split  longitudinally  including  a  5  cm. 
area  of  the  anterior  fornix,  which  by  a  few  snips  of  the  scissors  toward 
the  sides  is  somewhat  separated  from  the  bladder.  The  loose  con- 
nective tissue  is  separated  from  the  anterior  uterine  wall  in  the  same 
manner  as  on  the  posterior  wall,  and  then  both  uterine  walls  are  split 
up  to  the  peritoneum.  Then  the  hand  enters  freely  into  the  uterus  and 
readily  carries  out  version. 

We  are  able  with  the  aid  of  vaginal  Cesarean  section  in  all  normal 
pelves  and  in  such  pelves  whose  conjugata  is  not  less  than  7  1/2  to 
8  cm.,  at  any  period  of  pregnancy  or  labor,  even  without  pains  and 
with  a  completely  closed  cervix,  to  empty  the  uterus  of  its  contents 
within  a  jew  minutes,  and  thereby  to  obtain  a  living  child  in  case  the 
child  is  viable.     (Diihrssen.) 

This  result  is  obtained  per  vaginam  and,  as  a  rule,  without  open- 
ing the  peritoneal  cavity,  by  making  an  opening  in  the  fornix  and 
in  the  lower  uterine  segment,  so  that  further  resistance  of  the  soft 
parts  to  rapid  version  and  extraction  disappears. 


VAGINAL    CIOSARKAN    SECTION  409 

Since  1887,  Diihrssen  has  concerned  himself  with  rapidly  com- 
pleting dilatation  of  the  cervix  by  four  deep  cervical  incisions  and  with 
overcoming  the  resistance  of  the  lower  third  of  the  vagina  by  the  aid  of 
the  vagino-perineal  incision.  In  this  manner  it  was  possible  to  deliver 
a  li\'ing  child  in  primiparai  with  undilated  cervix  in  case  the  supra- 
vaginal part  of  the  cervix  had  disappeared.  He  recommended  this 
method  especially  for  rapidly  emptying  the  uterus  in  eclampsia. 

These  cervix  incisions  extend  up  to  the  attachment  of  the  vagina, 
and  the  vagino-perineal  incision  passes  through  the  levator  ani.  In 
making  cervical  incisions  he  makes  the  posterior  incision  first  and 
then  two  lateral.  The  incisions  are  made  after  introduction  of  the 
specula  and  always  between  two  applied  clamps  and  not  too  deep. 
The  four  deep  cervix  incisions  are  made  only  in  cases  where  there 
is  complete  dilatation  of  the  supravaginal  part  of  the  cervix.  Now, 
however,  in  these  cases,  too,  vaginal  Cesarean  section  is  indicated 
when  there  is  danger  for  mother  or  child,  when  the  rapid  completion 
of  the  labor  is  necessary,  and  when  the  use  of  a  metreurynter  does 
not  seem  to  be  indicated,  especially  if  one  wished  to  limit  himself 
to  one  or  two  longitudinal  incisions. 

Vaginal  Cesarean  section  in  these  latter  cases  is  very  easily  done, 
since  the  incisions  do  not  have  to  cut  much  of  the  supravaginal  part 
of  the  cervix  and  since  the  dilated  supravaginal  part  of  the  cervix 
presents  after  sagittal  division  of  only  a  little  of  the  anterior  and 
posterior  fornices  and  without  the  necessity  of  first  separating  the 
bladder  or  Douglas'  peritoneum. 

TECHNIC. 

After  the  precaution  of  emptying  the  bladder  and  the  rectum, 
an  ergotin  injection  is  given.  In  primiparae  a  vagino-perineal  in- 
cision is  made  which  cuts  the  levator  ani  and  the  constrictor  cunni 
and  renders  it  possible  to  pass  a  man's  fist  into  the  upper  vagina. 
The  introduction  of  specula  usually  stops  the  bleeding  by  pressure. 


4IO  VAGINAL   CELIOTOMY 

Two  lateral  volsella  and  two  strong  guiding  ligatures  are  applied  to  the 
cervix,  the  latter  to  be  used  when  the  volsella  are  taken  off.  The  pos- 
terior lip  of  the  cervix  is  split  longitudinally  up  to  the  beginning  of 
the  vagina  (Fig.  138).  In  lengthening  this  incision  posteriorly,  the  fornix 
is  split  about  4  cm.  and  the  speculum  is  introduced  into  this  opening 
to  push  off  the  peritoneum  of  Douglas  bluntly  from  the  posterior 
cervix  and  the  uterine  wall.  In  the  same  way  the  anterior  lip  and 
the  anterior  fornix  are  split  and  the  bladder  and  the  plica  are  pushed 
off  from  the  anterior  cervix  and  the  uterine  wall  (Fig.  139).  Passing 
out  from  this  longitudinal  incision  a  few  lateral  snips  of  the  scissors 
separate  the  anterior  vaginal  wall  over  the  bladder. 

To  make  this  method  more  easy  the  vaginal  wall  may  be  separated 
from  the  portio  by  a  2  cm.  transverse  incision.  In  this  manner  the 
anterior  and  the  posterior  uterine  walls  are  exposed  for  the  length 
of  6  cm.  First  the  posterior  and  subsequently  the  anterior  uterine 
wall  are  split  rapidly  by  a  few  scissor  strokes.  The  resulting  opening 
into  which  the  amniotic  sac  now  presents  (Fig.  140),  or  descends, 
must  be  large  enough  to  admit  a  large  man's  first.  The  hand  is  in- 
troduced, grasps  a  foot,  performs  version,  and  extracts  the  child.  If 
the  uterus  contracts  we  may  wait  for  the  spontaneous  expulsion  of 
the  placenta.  If  the  uterus  is  atonic,  separation  of  the  placenta  is 
done  and  the  uterus  is  thoroughly  packed.  The  posterior  wall  and 
then  the  anterior  wall  incisions  are  united  and  a  tiny  drain  is  in- 
troduced anteriorly  and  posteriorly  into  the  anteuterine  and  retrouter- 
ine spaces.  Only  if  there  are  abnormal  conditions  of  the  cervix,  as 
for  instance  scar  induration  or  unusual  character  of  the  subperitoneal 
connective  tissue,  does  one  occasionally  open  the  posterior  and  also 
the  anterior  peritoneum. 

Bleeding  from  the  perineo-vaginal  wound  is  not  great.  Bleeding 
from  the  uterine  incisions  may  be  fairly  severe,  but  is  stopped  by  the 
compression  of  version  and  extraction.  After-bleeding  is  slight  from 
these  wounds,  but  from  the  uterus  may  be  severe,  if  there  is  atony. 


VAc;i.\Ai.  ('I':sari:a.\  siicriox 


411 


Fig.  138. — Vaginal  Cesarean  Section. 

A  longitudinal  incision  is  made  through  the  posterior  lip  of  the  cervix.  The  subperitoneal 
space  is  entered  with  the  finger  and  the  peritoneum  dissected  upward.  The  incision  in  the  poste- 
rior fornix  is  then  lengthened  and  splitting  up  of  the  posterior  lip  of  the  cervix  may  be  continued 
up  to  the  peritoneal  fold  of  Douglas  shown  near  the  lower  angle  of  the  longitudinal  fornix 
incision.      {Method  of  Diihrsseii.) 


VAGINAL    CESAREAN    SECTION 


413 


Fig.  139. — ^\'aginal  Cesarean  Section. 

A  longitudinal  incision  is  made  through  the  anterior  lip  of  the  cervix  and  the  anterior  forni.x. 
The  introduced  finger  separates  the  bladder  from  the  anterior  wall  of  the  cervix  and,  with  or 
without  the  aid  of  two  small  transverse  incisions,  the  bladder  is  also  dissected  away  somewhat  from 
the  anterior  wall  of  the  vagina.  A  posterior  speculum  introduced  into  the  posterior  incision  of 
figure  138,  and  an  anterior  speculum  introduced  in  the  anterior  incision  of  figure  139  is  shown  in 
figure  140.     [Method  of  Diihrssev.) 


VA c;  1  .\,\ I ,  c: i;sA i^ f: a n  s r:c'r i o x 


415 


Fig.   140. — ^\^AGiNAL  Cesarean  Section. 

An  anterior  and  posterior  speculum  being  introduced  into  the  longitudinal  incision  of  Dtihrs- 
sen  after  the  preliminary  splitting  of  the  anterior  and  posterior  walls  of  the  cervix  shows  the  bulg- 
ing fetal  sac  and  discloses  the  area  of  the  anterior  and  posterior  walls  of  the  cervix  and  uterus, 
which  are  still  to  be  split  without  entering  either  the  anterior  or  posterioi  peritoneal  cul  de  sac. 
The  peritoneal  reflection  of  the  anterior  uterine  plica  and  of  the  posterior  Douglas  are  shown  in 
the   drawing.     The   lips  of  the  cervix  are  held  apart  by  volsella  or  provisional  sutures  or  both. 


VAGIXAL    CESAREAN    SECTION  417 

If  the  uterus  is  septic,  the  (hmger  of  infection  is  slight,  even  if 
the  peritoneum  is  oj)ene(l.  'I'he  splitting  is  carried,  as  a  rule,  as  little 
as  possible  aljove  the  internal  os,  and  it  should  include  both  walls 
to  avoid  furtlier  tearing  of  the  incision  and  to  avoid  rupture. 

Zweifel  does  the  operation  through  a  transverse  anterior  incision 
in  the  vagina.  Then  the  anterior  lip  of  the  cervix  is  grasped  and 
the  bladder  is  pushed  up  from  the  uterus,  the  anterior  lip  is  split,  so 
that  the  child  may  be  brought  out  by  forceps  or  by  version. 

Bumm  advises,  in  general,  the  splitting  of  the  anterior  wall  only. 

Kronig,  in  a  series  of  cases,  split  only  the  posterior  wall  and  pur- 
posely opened  the  peritoneal  cavity. 

Diihrssen  lays  stress  on  two  points : 

1.  For  the  extraction  of  a  large  child  we  must  use  the  vagino- 
perineal incision. 

2.  Cervix  must  be  split  longitudinally  up  to  peritoneal  reflexion, 
both  anteriorly  and  posteriorly,  to  avoid  the  danger  of  transverse 
tears  of  the  uterus  which  may  occur  through  deep  tearing  of 
a  single  longitudinal  incision. 

INDICATIONS. 

1.  Myoma — Rigidity — Stenosis  of  cervix. 
Scar  degenerations  of  cervix  and  fornix. 
Cervix  stenosis  after  amputation  of  cervix. 
Rigidity  of  cervix  causing  tenesmus  uteri. 

When  the  cervix  is  rigid  or  has  not  the  necessary  elasticity  to 
permit  of  use  of  metreur3mter  or  of  combined  version. 

2.  Danger  stage  of  the  mother  which  may  be  overcome  or  helped 
by  emptying  uterus  when  cervix  is  closed  and  not  dilated. 
Diseases  of  lung,  heart,  kidney,  nephritis. 

Early  loosening  of  the  placenta. 

Severe  bleedings. 
27 


41 8  VAGINAL    CELIOTOMY 

Pernicious  vomiting. 

Chorea  gravidarum. 

Retroversion  of  gravid  uterus  with  incarceration. 

Torpid  uterus  in  narrow  pelvis. 

3.  Impending  death  of  mother,  to  extract  living  child. 

4.  Placenta  previa.  Bumm  advises  vaginal  hysterotom.y  because 
it  may  save  life  in  women  who  at  the  beginning  of  cervix 
dilatation  have  bled  profusely.  At  any  rate,  he  believes  it  su- 
perior to  classical  Cesarean  section  in  view  of  the  small  amount 
of  injury  done;  superior  to  all  methods  of  dilatation  because 
of  the  certainty  in  stopping  bleeding. 

5.  In  the  interest  of  the  child,  even  if  mother  is  in  no  danger. 
In  cases  where  the  supravaginal  area  of  cervix  is  dilated,  but 
the  portio  is  still  an  obstacle,  where  metreurynter  or  deep  cervix 
incisions  do  not  promise  success.  If  head  is  low  and  specula 
show  only  an  edge  of  the  portio,  use  simple  cervix  incisions. 
If  head  is  high,  it  is  better  to  do  vaginal  Cesarean  section  and 
then  version. 

6.  Septic  edema  of  the  collum  with  fever. 

7.  Eclampsia.  Immediate  conservative  vaginal  Cesarean  section 
is  advised. 

8.  Sepsis  after  abortion,  especially  criminal;  empty  uterus  and 
then  remove  it. 

In  eclampsia  Diihrssen  advises  immediate  emptying  of  the  uterus, 
after  the  first  seizure,  with  any  of  the  various  methods  of  delivery,  each 
adapted  to  the  suitable  case,  and  says  that  he  gets  better  results  for 
mother  and  child  than  with  the  more  conservative  treatment.  With 
narrow  pelvis  and  conjugata  less  than  7  1/2  to  8  cm.  he  advises  the 
classic  Cesarean  section.  On  the  other  hand,  with  all  severe  ob- 
stacles to  delivery  limited  to  soft  parts  and  with  danger  to  life  of 
mother  or  child,  when  occurring  with  closed  undilatable  cervix,  use 
vaginal  Cesarean  section,  which  is  done  extraperitoneally. 


\A(;i\AL    CESAREAN    SECTION  419 

Zvveifel  says  that  eclampsia  in  his  clinic  had  been  treated  for  years 
with  narcotics,  some  with  chloroform,  some  with  repeated  doses  of 
morphine  as  recommended  by  G.  \Y'it,  also  with  jjacks  and  sweat 
baths  and  then  delivered  as  soon  as  possible,  though  never  by  forcible 
opening  of  the  cervix,  so  that  of  forty-nine  cases,  sixteen  died — a  mor- 
tality of  T,2  percent.  After  a  change  to  active  therapy,  through  lim- 
itation of  the  narcotics  to  the  period  of  delivery  by  operation 
(Diihrssen),  through  earliest  delivery  after  the  first  attack  (Diihrssen), 
and  through  the  reintroduction  of  vein  bleeding,  out  of  eighty  cases 
only  twelve  were  lost — a  mortality  of  15  per  cent. 

8.  Carcinoma.     If  carcinoma  is  limited  to  the  uterus  in  pregnancy 
the  operation  is  done  solely  in  the  interest  of  the  mother  im- 
mediately  after    making    the    diagnosis,    and    radical  vaginal 
Cesarean  section  should  be  undertaken  at  any  period  of  preg- 
nancy or  labor. 
Radical   vaginal   Cesarean    section    includes   only  those   cases   in 
which  the  uterus,  immediately  after  its  emptying,  is  removed  vaginally, 
as  in  the  case  of  carcinoma  uteri  or  in  septic  uteri. 

The  carcinoma  should  be  removed  with  the  curette  and  the  exposed 
surface  should  be  treated  with  the  Paquelin.  If  the  vagina  is  small, 
the  vagino-perineal  section  is  made.  After  the  cervix  has  been  grasped 
laterally  by  two  volsella  and  by  two  ligatures,  the  vagina  is  loosened 
circularly  from  the  portio  and,  in  addition,  a  longitudinal  incision 
is  made  in  the  anterior  vaginal  wall.  Posteriorly  the  Douglas  perit- 
oneum is  pushed  up  and  anteriorly  the  bladder  and  plica  are  pushed 
oft"  from  the  uterus  bv  inserted  specula.  Then  the  anterior  and 
posterior  uterine  walls  are  split.  The  volsella  are  taken  oft"  and 
the  uterus  is  emptied  of  child  and  placenta.  Splitting  of  the  anterior 
and  posterior  walls  is  then  continued,  which  opens  the  plica  and 
Douglas  peritoneum,  and  the  splitting  is  continued  until  the  uterus 
is  divided  into  two  halves  and  then  removed.  This  constitutes  the 
Peter  ^Nliiller  method  of  vaginal  uterine  extirpation. 


420  VAGINAL   CELIOTOMY 

This  vaginal  method  is  indicated  only  if  carcinoma  is  still  limited 
to  the  cervix  and  if  the  parametria  are  not  deeply  involved. 

Diihrssen  says  that  in  hysterectomy  for  carcinoma  the  uterus 
should  be  split  and  delivered  and  then  the  ligaments  should  be  ligated, 
as  death  from  bleeding  may  result  if  time  is  taken  to  tie  off  the  liga- 
mentum  cardinalia  before  splitting  the  uterus. 

On  April  i,  1898,  Diihrssen  proposed,  in  severe  eclampsia  in  the 
first  seven  months,  to  empty  the  uterus  quickly  by  opening  the  anterior 
fornix  and  splitting  the  anterior  wall  of  the  cervix  and  of  the  lower 
uterine  segment. 

On  April  24,  1896,  Diihrssen  made  his  first  vaginal  Cesarean  sec- 
tion, successful  as  to  mother  and  child. 

In  July,  1896,  appeared  Diihrssen's  monograph  entitled  "Der 
vaginale  Kaiserschnitt." 

In  October,  1896,  Acconci  published  the  history  of  a  case  of  a 
IX-para,  twenty-eight  weeks  pregnant  with  a  carcinoma  of  the  anterior 
lip  of  the  cervix. 

In  July,  1895,  he  removed  this  carcinoma  with  Paquelin,  made 
a  circular  incision  about  the  portio,  opened  the  plica  and  Douglas 
peritoneum,  and  tied  off  the  base  of  the  parametrium.  He  then  made 
a  longitudinal  splitting  of  the  posterior  and  anterior  uterine  wall  until 
the  amniotic  sac  was  visible.  The  opening  was  not  large  enough 
for  extraction  and  he  tried  mechanical  dilatation  with  the  dilator 
of  Mauri,  and  then  did  version  with  extraction  of  the  living  child. 
He  continued  the  splitting  in  the  anterior  wall,  loosened  the  placenta 
manually,  extirpated  and  removed  the  uterus  after  complete  ligation 
of  the  ligaments,  and  sewed  the  upper  parts  of  the  ligamenta  lata 
to  the  vaginal  wound  edges.  The  patient  died  in  collapse  after  an 
error  in  diet  associated  with  profuse  diarrhea.  He  reported  this 
case  sixteen  months  later  without  any  critical  observations,  but  with 
the  claim  for  priority  in  the  matter  of  vaginal  Cesarean  section. 

In  his  monograph  Diihrssen  mentioned  two  methods : 


VAGINAL  CESAREAN  SECTION  42 1 

1.  The  vaginal  opening,  emptying,  and  sewing  of  the  uterus  with- 
out entering  the  peritoneal  cavity  through  the  vaginal  opening. 

2.  Emptying  and  extirpation  of  the  uterus. 

The  first  is  analogous  to  Sanger's  Cesarean  section  and  the  second 
to^he  Porro  operation. 

Acconci,  according  to  Diihrssen,  could  only  claim  priority  as  regards 
method  "2,"  since  vaginal  Cesarean  section  means  the  getting  of  a 
living  child  at  the  end  of  pregnancy  with  preservation  of  the  uterus. 


THE  METREURYNTER  INCISION. 

Vaginal  Cesarean  section  is  greatly  simplified  when  the  cervix 
incision  is  done  with  the  aid  of  a  metreurynter  introduced  into  the 
uterus  and  then  filled. 

A  metreurynter  is  introduced  into  the  uterus  and  is  filled  with  anti- 
septic solution.  Strong  manual  traction  is  exerted  on  the  tube.  In 
favorable  cases  the  collum  becomes  so  dilated  that  the  bag  may  be 
extracted,  and  then  delivery  of  the  child  takes  place  by  any  desired 
method.  If  manual  traction  on  the  tube  of  the  metreurynter  does  not 
produce  dilatation  of  the  collum,  but  merely  serves  to  draw  the  cervix 
down  toward  the  introitus,  then  further  traction  is  carried  out  by  an 
assistant.  The  anterior  fornix  is  exposed  by  a  Doyen  retractor,  and 
the  operator,  with  the  aid  of  only  a  mouse-toothed  forceps  and  one 
pair  of  scissors,  splits  the  anterior  lip  longitudinally  through  the 
anterior  fornix,  which,  with  an  added  transverse  incision,  forms  two 
flaps  which  are  separated  from  the  bladder.  The  bladder  is  then 
separated  from  the  anterior  wall  of  the  cervix,  and  this  is  split  still 
further  until  the  metreurynter  is  almost  ready  to  make  its  exit  through 
the  artificial  opening. 

It  is  generally  advisable,  so  far  as  the  anterior  lip  of  the  cervix  is 
concerned,  to  use  the  inverted  1 -incision  instead  of  the  wide  transverse 
incision.  This  exposes  the  bladder  and  makes  its  separation  easy, 
and  no  difficulty  whatever  is  experienced  on  introducing  the  speculum 
between  the  bladder  and  the  uterus  and  then  splitting  the  cervix 
from  the  external  os  up.  The  incision  in  the  vagina  retracts  to  such 
an  extent  after  labor  that  it  does  not  even  require  sewing.  If  the 
metreurynter  cannot  be  extracted  after  the  splitting  of  the  anterior 
lip  has  extended  up  to  the  peritoneal  reflection,  then  the  posterior  wall 
and  the  posterior  fornix  are  incised  longitudinally. 

422 


Till':  .\ii:Tki;rRY.\Ti:R   ixcisio.x 


423 


P'iG.   141. — ^Metreurynter  Incision. 

The  metreurynter  has  been  introduced  into  the  cervix  and  is  filled  wiili  lysol  solution.  By 
pulling  on  the  tube  of  the  metreurynter  the  cervi.x  is  brought  well  down  tmvard  the  vulva  so  that 
the  anterior  speculum  discloses  the  entire  anterior  fornix.  The  dotted  line  shows  the  somewhat 
curved  transverse  vaginal  incision  which  is  to  be  made.  The  upper  lip  of  the  transverse  incision 
is  picked  up  with  artery  forceps  and  the  bladder  is  dissected  away  from  the  anterior  wall  of  the 
cervix  with  the  gauze-covered  index  finger. 


THE  metreurv.\ti;r  incision 


425 


Fig.  142. — Metreurynter  Inxisiox. 

After  the  wide  transverse  incision  has  been  made  and  the  bladder  has  been  dissected  awav 
from  the  anterior  wall  of  the  cervix  up  to  the  peritoneal  plica,  the  anterior  speculum  is  introduced 
to  hold  the  bladder  up  and  the  cer\-ix  is  split  longitudinally.  Constant  traction  is  exerted  on  the 
metreurj'nter  and  the  upper  areas  of  the  cervix  come  more  into  view.  Upward  pressure  of  the 
anterior  speculum  not  alone  lifts  the  bladder  up,  but  dissects  the  peritoneal  plica  away  from  the 
anterior  wall  of  the  uterus  so  that  the  incision  may  be  extended  up  for  a  considerable  distance. 
In  many  cases  the  anterior  incision  suffices,  and  this  part  of  the  operation  is  completed  when  the 
metreurvnter  makes  its  exit. 


Till';  .Mi;rRi;i  RV.\ri:R   ixcisiox 


427 


Fig.   143. — Metreurynter  Ixcisiox. 

If  the  metreunnter  in  figure  142,  does  not  make  its  exit  through  the  anterior  longitudinal 
incision,  the  tube  is  pulled  toward  the  urethra  and  the  posterior  wall  of  the  cervix  is  incised 
in  a  longitudinal  manner  along  the  dotted  line.  Before  the  posterior  splitting  is  done,  a  transverse 
incision  may  be  made  in  the  posterior  fornix  with  dissection  up  to  the  cul  de  sac  of  Douglas,  or 
else  the  longitudinal  splitting  is  carried  out  with  separation  and  dissection  up  to  the  cul  de  sac 
of  Douglas,  as  in  figure  13S,  of  \"aginal  Cesarean  Section. 


THE    MKTRKURYX  ri:R    INCISION  429 

ConccrniiiL!;  the  (lucstion  as  to  whether  tlie  anterior  (;r  Ijoth  anterior 
and  posterior  walls  should  be  incised,  there  still  exists  uncertainty  in 
many  minds.  At  full  term  the  splitting  of  Ijoth  the  anterior  and 
posterior  walls  makes  extraction  of  the  child  more  easy  and  guards 
the  mother  from  further  tearing  of  the  incision,  which  may  occur  if 
only  the  anterior  sphtting  is  done.  The  metreurynter  incision  has  an 
additional  advantage,  inasmuch  as  it  permits  of  each  case  being 
treated  according  to  the  individual  conditions  as  they  develop.  If 
the  large  bag  cannot  be  readily  extracted  after  the  anterior  incision 
is  made,  then  the  posterior  lip  also  is  incised.  As  soon  as  this  pos- 
terior incision  enters  i  cm.  into  the  posterior  fornix,  the  Douglas' 
peritoneum  is  pushed  upward  from  the  posterior  wall  by  the  fingers 
and  the  posterior  lip  is  split  further  until  the  balloon  comes  readily  out. 
This  method  reduces  the  danger  of  injury  to  the  uterus  to  a  minimum. 

The  metreurynter  incision  has  the  following  advantages : 

1 .  It  is  clone  immediately  after  a  trial  of  metreurynter  has  proven 
this  rubber  bag  alone  to  be  insufficient  to  accomplish  dilatation. 
Hence  the  use  of  the  metreurynter  is  at  the  same  time  the  first  step 
of  this  operation. 

2.  Traction  on  the  tube  of  the  metreurynter  brings  the  portio  near 
to  the  introitus.  One  speculum  suffices  to  bring  the  portio  and  both 
fornices  into  easy  reach.  Traction  on  the  metreurynter  and  the 
holding  of  the  speculum  can  be  done  by  one  assistant. 

3.  With  the  splitting  of  the  anterior  and  perhaps  also  of  the  pos- 
terior wall,  traction  on  the  metreurynter  brings  the  higher  areas  of  the 
collum  successively  within  reach  of  the  scissors. 

4.  Traction  on  the  metreurynter  makes  the  parts  of  the  cervix  and 
uterine  wall  to  be  incised  so  anaemic  that  the  operation  is  almost 
bloodless.  This  is  of  special  advantage  in  placenta  previa,  so  that 
the  metreurynter  incision  constitutes  an  ideal  therapy  in  those  cases 
of  placenta  previa  in  which  it  is  of  special  importance  to  obtain  a 
living  child. 


430  VAGINAL   CELIOTOMY 

5.  On  account  of  the  absence  of  bleeding,  it  is  possible  to  operate 
without  haste  and  with  the  greatest  clearness.  One  can  make  the 
subsequent  sewing  of  the  incision  easier  by  passing  one  or  two  sutures 
through  the  uterine  wall  at  the  upper  end  of  incision.  With  the  aid 
of  these  sutures  after  the  uterus  is  emptied,  the  area  to  be  sewn  can  be 
drawn  down  so  far  that  it  can  be  readily  sewn. 

6.  The  metreurynter  incision  changes  vaginal  Cesarean  section 
from  a  major  heroic  operation  into  an  easy  procedure.  It  is  only 
necessary  to  place  the  patient  in  proper  position  with  the  leg-holders, 
and  with  the  aid  of  one  assistant  the  operation  is  done  with  one  specu- 
lum, one  bag,  one  pair  of  scissors,  and  one  mouse-tooth  forceps. 

The  metreurynter  incision  is  indicated  particularly  in  eclampsia, 
early  loosing  of  the  placenta,  placenta  previa,  danger  to  the  child 
through  protracted  labor  or  through  prolapse  of  the  cord,  and  anoma- 
lies of  the  cervix  which  make  its  dilatation  impossible. 

This  operation,  because  of  its  simplicity,  when  combined  with 
the  extraperitoneal  inguinal  Cesarean  section  of  Solms,  is  of  great  value 
in  narrow  pelvis.  In  addition  it  permits  of  thorough  drainage  through 
the  vagina. 


MINOR  VAGINAL  CESAREAN  SECTION. 

\Yq  may  apply  the  term  minor  \'aginal  Cesarean  section  to  the 
splitting  of  the  anterior  and  posterior  lips  of  the  cervix  up  to  the  in- 
ternal OS,  after  preliminary  separation  of  the  bladder  from  the  cervix 
and  of  the  Douglas  peritoneum  from  the  posterior  wall  of  the  cervix, 
for  the  purpose  of  accomplishing  a  rapid  and  relatively  bloodless 
emptying  of  the  uterus  in  the  early  months  of  pregnancy  or  in  impend- 
ing unavoidable  abortion  in  the  third,  fourth,  and  fifth  months  of 
pregnancy. 

There  are  cases  where,  with  elongatio  colli  or  with  rigid  cervix, 
the  ordinary  methods  of  dilatation  are  long  and  tedious.  There  are 
other  cases  where,  through  severe  cervical  rigidity,  haste  is  ncessary 
to  avoid  continued  loss  of  blood.  There  are  other  cases  where,  on 
account  of  the  patient's  general  state,  a  rapid  emptying  of  the  uterus 
is  desired.  In  cases  of  pernicious  vomiting,  where  haste  is  imperative, 
this  method  offers  a  rapid  means  of  accomplishing  the  therapeutic 
procedure,  the  emptying  of  the  uterus.  In  some  cases  of  tuberculosis 
where  the  advance  of  pregnancy  is  contraindicated,  this  method,  too, 
finds  an  indication. 

Doderlein  calls  laminaria,  bougies,  metreurynter,  iodoform  gauze 
packing,  etc.,  breeding  spots  of  infection. 

These  are  the  means  at  our  hands  for  dilating  the  cervix  in  the 
cases  above  mentioned,  an  additional  method  being  the  dilatation 
with  any  of  the  various  forms  of  cervical  dilator. 

Experience  has  taught  me  to  avoid  this  last  method  as  much  as 
possible,  and  I  have  reached  the  conclusion  that  vaginal  Cesarean 
section,  while  filling  a  most  desirable  place  at  the  normal  end  of 
pregnancy  and  with  a  living  child,  is,  as  Wertheim  says,  often  indi- 
cated  in  any  period  of    gestation.     I    have  used  this  method  many 

431 


432  VAGINAL   CELIOTOMY 

times  with  very  happy  results.  A  transverse  incision  is  made  in  the 
posterior  fornix  and  the  peritoneum  of  Douglas  is  pushed  up  and 
dissected  away  from  the  posterior  wall  of  the  uterus.  A  transverse 
incision  is  made  on  the  anterior  wall  of  the  cervix  and  the  bladder 
is  pushed  up  from  the  anterior  wall  of  the  uterus  as  far  as  possible. 
It  is  of  great  help  to  add  a  longitudinal  incision  to  the  transverse,  for 
the  plica  is  more  readily  brought  into  view  and  the  point  to  which  the 
splitting  of  the  anterior  lip  may  be  carried  is  in  evidence,  and  later 
on  it  is  easier  to  reach  the  upper  end  of  this  incision  in  the  cervix 
when  closing  with  continued  or  interrupted  suture.  After  the  pre- 
liminary separation  of  the  bladder  and  the  dissection  upward  of  the 
Douglas  peritoneum,  the  cervix  is  grasped  by  volsella  applied  laterally 
and  each  lip  of  the  cervix  is  split  up  to  the  internal  os.  The  second 
finger  of  either  hand  is  then  introduced  into  the  uterus  and  the  other 
hand  is  applied  to  the  fundus  of  the  uterus  through  the  abdominal 
wall,  and  the  entire  ovum  can  safely  and  rapidly  be  separated  from  its 
contact  with  the  uterine  wall  and  then  extracted  after  rupture  of  the 
amniotic  sac.  If  removal  in  toto  is  not  possible,  we  have  a  large 
opening  through  which  placental  forceps  can  empty  the  uterus  of  its 
contents. 

A  hypodermic  of  ergotole  usually  produces  a  firm  contraction 
of  the  uterus  (this  is  usually  given  before  the  finger  or  hand  is 
introduced  into  the  uterus).  The  uterine  cavity  is  then  packed 
with  iodoform  gauze  and  a  narrow  strip  is  allowed  to  pass  out  through 
the  cervix.  This  strip  is  kept  in  place  during  the  sewing  of  the  split 
cervix,  so  that  we  may  be  certain,  especially  when  dealing  with  an 
elongatio  colli,  that  the  lumen  is  not  obliterated  by  any  suture.  The 
posterior  incision  is  closed  first. 

I  use  interrupted  No.  3  chromic  sutures,  the  first  one  not  being 
cut  until  the  second  one  is  tied ;  the  second  one  not  being  cut  until  the 
third  is  tied.  In  this  way  we  are  able  to  bring  the  upper  areas  of 
the  longitudinal  cervix  incision  into  ready  contact  with  the  needle. 


.MINOR    VAGINAL    CESAREAN    SECTION 


4^3 


•j*. 


Fig.  144. — Minor  Vaginal  Cesarean  Section. 

With  the  aid  of  a  transverse  and  longitudinal  fornix  incision  the  bladder  is  separated  from' 
the  anterior  wall  of  the  cervix  and  from  the  anterior  wall  of  the  vagina  and  is  lifted  up  by  an  anterior 
speculum  so  that  the  anterior  wall  of  the  cervix  is  disclosed  up  to  the  peritoneal  fold. 


28 


MINOR    VAGIXAL    CESAREAN    SECTION 


435 


Fig.  145. — Minor  Vaginal  Cesarean  Section. 

The  anterior  lip  of  the  cervix  is  spUt  along  the  median  line  up  to  the  reflection  of  the  perit- 
oneal plica. 


MINOR   VAGINAL    CESAREAN    SECTION 


437 


Fig.  146. — Minor  Vaginal  Cesarean  Section. 

A  transverse  incision  has  been  made  in  the  posterior  lip  of  the  cer\'ix,  and  the  posterior  fornix 
has  been  separated  from  the  posterior  wall  of  the  uterus,  and  the  fold  of  Douglas  has  been  pushed 
upward.  The  posterior  lip  of  cervix  is  now  incised  along  the  median  line  up  to,  but  not  through, 
the  Douglas  peritoneum. 


MINOR    VAGINAL    CESAREAN    SECTION 


439 


Fig.  147. — Minor  Vaginal  Cesarean  Section. 

The  cervix  is  lifted  upward  and  the  incision  in  the  posterior  lip  of  the  cervix,  which  extended 
up  to  the  Douglas  peritoneum,  is  closed  by  interrupted  chromic  sutures. 


MINOR    VAGINAL    CESAREAN    SECTION 


441 


Fig.  148. — Minor  Cesarean  Vaginal  Section. 

The  cervix  is  pulled  down  sharply,  the  anterior  speculum  holds  the  bladder  out  of  the  wav, 
and  the  incision  in  the  anterior  lip  of  the  cervix  is  closed  from  above  downward  bj-  interrupted 
chromic  catgut  sutures.  During  this  step,  a  strip  of  gauze  which  has  been  passed  into  the  uterus 
almost  fills  the  lumen  of  the  cervix.  Care  must  be  exercised  that  this  should  not  be  caught  by 
any  of  the  sutures.  On  completion  of  the  sewing  this  gauze  is  removed  and  another  strip  is  passed 
up  into  the  uterus. 


MTXOR    VAC.rXAL    CKSAKKAX    SKCTION  443 

The  incisi<)n  in  tlic  anterior  lip  is  then  closed  in  the  same  manner, 
the  cervix  being  well  pulled  down  and  the  bladder  being  retracted 
so  that  the  upper  end  of  the  incisi(jn  may  be  closed  with  certainty. 
In  addition,  we  obtain  by  this  manipulation  a  clear  view  of  the  plica, 
so  that  if  through  stretching  of  the  opening  during  any  of  the  previous 
manipulations  the  plica  has  been  opened,  it  may  be  closed. 

Here  also  the  first  ligature  is  not  cut  until  the  second  has  been 
tied  and  the  second  not  cut  until  the  third  has  been  tied,  for  the 
reasons  above  mentioned. 

After  the  cervical  slits  have  thus  been  united  the  transverse  incision 
in  the  posterior  fornix  is  closed  by  interrupted  sutures,  and  the  trans- 
verse and  longitudinal  incisions  in  the  anterior  fornix  are  closed  in 
the  same  manner.  The  intrauterine  packing,  the  lower  end  of  which 
extends  through  the  cervix,  may  be  retained  if  desired,  or  it  may  be 
drawn  out  and  a  small  wick  of  iodoform  gauze  introduced  through 
the  cervix  into  the  uterine  cavity.  A  tiny  wick  is,  as  a  rule,  introduced 
into  the  antecervical  and  retrocervical  areas  through  a  space  between 
any  two  interrupted  sutures  closing  the  transverse  posterior  and 
anterior  vaginal  incision.  The  vagina  is  then  packed  with  gauze 
and  ergotole  is  administered  at  three-hour  intervals  for  the  succeeding 
few  days.  The  wicks  in  the  antecervical  and  retrocervical  areas 
(the  ends  of  which  have  been  brought  out  to  the  vulva)  are  removed 
without  distrubing  the  vaginal  packing  at  the.  end  or  twenty-four 
hours.  The  intracervical  strip  of  gauze  and  the  vaginal  packing 
are  removed  at  the  end  of  five  or  six  days,  after  which  vaginal  douches 
may  be  given  daily. 


INDEX 


Abdominal  and  vaginal  routes,  choice, 

64 
Abel,  64,  69,  346,  349,  359,  360,  361,  405 
Abscess,    pelvic,    posterior    vaginal    celi- 
otomy for,  48 
Acconci,  420,  421 
Adhesions,    posterior    vaginal    celiotomy 

for,  37 
Adnexa,     conservative     operations     on, 
vaginal  route  for,  123 
delivery   of,  by  anterior    vaginal   celi- 
otomy, 103,  104 
by  posterior  vaginal  celiotomy,  38 
disease  of,  346 

choice  of  operation,  346,  348 
vaginal   celiotomy  for,   advantages, 
348 
indications,  348 
limitations,  348 
mortality,  346 
technic,  349 
examination      by      posterior      vaginal 

celiotomy,  37 
inflammation  of,  operation  for,   114 
Alexander-Adams  operation,  154 

vaginal    celiotomy    and,    choice    of, 
130 
Amputation  of  cervix,  198,  235 
Anterior  vaginal  celiotomy,  58 
advantages,  62 
Alexander-Adams  operation  and, 

choice  of,  130 
contraindications,  64,  115 
development  of,    131 
diagnostic  value,  117 
Duhrssen's,  60 
entering  peritoneum,  90 
essential  conditions,  63 
for  conservative  operations,  1 1 7 
for  cystic  tumor,  114 
for  delivery  of  adnexa,  103,  104 
of  uterus,  103,  142 


Anterior  vaginal  celiotomy  for  enuclea- 
tion of  myomata,  60 
for  extrauterine  pregnancy,  114 
for  fibroids,  115,  117 
for  fixation  of  round  ligaments,  130 
for  foreign  bodies  in  bladder,  89 
for  inflammation  of  adnexa,  114 
for  intraligamentous  cysts,  61 
for  myomata,  61,   129 
for  ovarian  cysts,  60,  123 
for  ovariotomy,  60 
for  prolapse,  60 
for  pyosalpingectomy,   115 
for  retrodeviations,  129 
for  retroflexion,  129 
for  retroversion,  129 
for  salpingo-oophorectomy,   114 
for      separating      bladder      from 

vagino-uterine  connections,  67, 
70,  71 
for    shortening  round    ligaments, 

130 
for  uterine  malpositions,  113 
for  vaginal  fixation,  60 

suspension,  130 
for  vesical  calculi,  89 

fistulas,  89 

suspension,  130 
history,  58 

hysterectomy  through,  113,  114 
indications,  62,  iii 
mortality,  63 
new  method,  technic,  70 
shortening   round    ligaments    by, 

60,  154 
technic  of  new  method,  70 
Artificial  sterility,  166 
Atlee,  38 

Bandler's   operation   for  total  prolapse 
of  uterus,  205 
simple  vaginal  hysterectoiny,  286 


445 


446 


INDEX 


Bladder,     foreign     bodies     in,     vaginal 
celiotomy  for,  89 
prolapse  of,  209 

separating  of,  by  colpotomy,  71 
from  cervix,  71 
from  fornix,  78 
from  uterus,  71 
from  vaginal  wall,  78,  89 
from  vagino-uterine  connection,  67, 

70 
in  multiparse,  77 
in  nullipara,  72 
Boldt,  61 

Broad  ligament,  lower  part,  ligation  of, 
in  vaginal  hysterectomy,  292,  321,  322 
Bumm,  407,  417,  418 
Burger,  69,  360 

Calculi,  vesical,  vaginal  celiotomy  for, 

89 
Carcinoma  of  cervix,  419 
Cervical  myomata,  392,  394 
Cervix,  amputation  of,  198,  235 

carcinoma  of,  419 

hypertrophied,  209 

separating  of  bladder  from,  71 
Cesarean  section,  vaginal,  407 
in  eclampsia,  418 
indications,  417 
Metreurynter  incision,  422 
minor,  43 1 
radical,  419 
technic,  409 
Choice  of  operation,  113 
Chrobak,  61,  64 

Colpoceliotomy.      See  Anterior  and  Pos- 
terior Vaginal  Celiotomy. 
Colpoperineorrhaphy,  high,  249 
Colpotomy  for  separating  bladder,  71 
Conservative    operations,    anterior    vag- 
inal celiotomy  for,  117 
Corpus  pedicled  myomata,  397 

subserous  myomata,  397 
Cystic  tumors,  unilocular,  operation  for, 

114 
Cystocele  and  vagino-suspension,  160 

causes,  206 

definition,  205 

incision  for,  89 

operation  for,  160,  209 

posterior,  210 


Cysts,  intraligamentous,   extirpation    by 
anterior  vaginal  celiotomy,  61 
ovarian,  359 

anterior    vaginal    celiotomy  for,  60, 

123 
in  multipara,  361 

posterior  vaginal  celiotomy  for,  38 
relative  mortality,  360 

Dermoids,  359 

Descensus  uteri,  causes,  207,  208 
definition,  205 

vaginal  fixation  for,  162,  178 
vaginae  with  prolapse  of  uterus,  205 
Differential  diagnosis,   posterior  vaginal 

celiotomy  for,  28 
Doderlein,  27,  35,  54,  57,  431 
hysterectomy,  54 
first  step,  35 
preliminary  step,  54 
Douglas  pouch,  entrance  into,  17 
Doyen,  400 
Drainage,     posterior    vaginal    celiotomy 

and,  47,  53 
Diihrssen,   17,  38,   58,  59,  60,  62,  63,  64, 
65,  70,  114,  117,  132,  137,  139,  141, 
143,    144,    161,    162,    282,    347,    349, 
358,    407,   408,   409,   411,   417,   418, 
419,  420,  421 
anterior  vaginal  celiotomy,  60 
technic  of  vaginal  fixation,    132,    137, 

141,  143 
in      non-childbearing      women, 
162 
transverse  incision,  65 
vaginal  Cesarean  section,  407 
Dysmenorrhea,  constitutional,   285,  286 
Dystocia  in  labor  after  vaginal  fixation, 
131,  139-  153 

Eclampsia,  vaginal  Cesarean  section  in, 

418 
Ectopic  gestation,  358 

conservative  treatment,  124 
intrauterine  pregnancy  and,  differ- 
entiation, 28 
operation  for,  114 
tumors,  358 
Enucleation    of    myomata    by    anterior 

vaginal  celiotomy,   60 
Evidement  of  Doyen,  400 


INDEX 


447 


Examination  ])y  posterior  vaginal  celi- 
otomy, 3  7 

Extrauterine  ]irc'^Miancy,  358.  See  also 
Ectopic  Geslalion . 

Exudates,  posterior  vaginal  celiotomy 
for,  48 

Fallopian  tubes,  diseases  of,  346.      .See 

also  Adnexa. 
Fchling,  60 
Fibroids,  anterior  vaginal  celiotomy  for, 

115.  117 
Fibromyomata,  392 
Fibrosis  uteri,  283 

medical  treatment,  285 
operative  treatment,  286 
Fistula,  vesical,  vaginal  celiotomy  for,  89 
Foreign     bodies     in     bladder,      vaginal 

celiotomy  for,  89 
Fornix,   anterior,   separating  of   bladder 

from,  78 
Fritsch,  58 

GOFFE,    62 

Hematocele,  parametritis  and,  differ- 
entiation by  posterior  vaginal  celi- 
otomy, 48 

Hypertrophied  cervix,  209 

Hysterectomy,    anterior    vaginal   route, 

113.  114 
Doderlein's,  54 
first  step,  35 
preliminary^  step,  54 
vaginal,    283,   363.      See   also    Vaginal 
Hysterectomy. 
Hysteromyomectomy,  399 
evidement  of  Doyen  in,  400 
morcellement  in,  405 

Incarcerated      uterus,     replacing     by 

posterior  vaginal  celiotomy,  37 
Incision  for  c^^stocele,  89 

for  entering  peritoneum,  90 

for  posterior  vaginal  celiotomy,  1 7 

inverted-T,  89,  144,  145 
in  hysterectomy,  363 

longitudinal,  in  separating  ureters,  77 

Metreurynter,  422 

Schuchard's,  399 

transverse,  in  separating  bladder,  72 


Inelasticity,  prolajwe  and,  207,  208 

Intraligamentous   cysts,    extirpation   by 
anterior  vaginal  celiotomy,  61 

Inverted-T  incision,  89,  144,  145 
in  hysterectomy,  363 

Irrigation    after    posterior   vaginal    celi- 
otomy, 53 

KOSSMANN,   60 

Kronig,  417 
Kustner,  59 

Labor  after  vaginal  fixatjon,  131 

dystocia    in,     after     vaginal    fixation, 

131,  139.  153 
Landau,  61 

Levator  ani  muscles,  prolapse  and,  206 
Longitudinal  incision  for  posterior  vag- 
inal celiotomy,  1 7 

in  separating  ureters,  77 

Mackenrodt,  17,  70,  132 

technic,  132 
Martin,  59,  70,  135,  142,  358 

technic  of  vaginal  fixation,  135 
Menopause,  vaginal  fixation  in,  161 
Menstruation  in  fibrosis  uteri,  284 
Metreurynter  incision,  422 
Minor  vaginal  Cesarean'  section,  43  i 
Morcellement    in    vaginal    hystero-myo- 

mectomy,  405 
Miiller,  60,  391,  419 

vaginal  uterine  extirpation,  419 
Multiparse,  separation  of  bladder  in,  72, 

77 
vesico-uterine  membrane  in,  72 
Myomata,     anterior     vaginal    celiotomy 

for,  61 
cervical,  392,  394 
corpus  pedicled,  397 

subserous,  397 
deep,  397 
enucleation    of,    by    anterior    vaginal 

celiotomy,  60 
in  Douglas'  cul-de-sac,  397 
interstitial,  397 
intraligamentous,  397 
portio,  394 
submucous,  397 

subserous,  in  Douglas'  cul-de-sac,  397 
vaginal  celiotomy  for,  129,  392 


448 


INDEX 


Myomectomy,  392 
vaginal,  124 

Ovariotomy,  vaginal  route,  60,  359 
Ovary,    cyst    of,    359.      See    also    Cysts, 
Ovarian. 
diseases  of,  346.      See  also  Adnexa. 

Parametritis,      posterior,      hematocele 
and,     differentiation     by     posterior 
vaginal  celiotomy,  48 
posterior  vaginal  celiotomy  for,  47 
Pean,  360 

Pelvic    abscess,    posterior    vaginal    celi- 
otomy for,  47 
peritonitis,  posterior  vaginal  celiotomy 
for,  48 
Perineum,     repair     of,     after     prolapsus 

uteri,  210 
Peritoneum,  entering  in  anterior  vaginal 
celiotomy,  90 
in  vaginal  hysterectomy,  321 
entrance  into,   27 
Peritonitis,      pelvic,      posterior      vaginal 

celiotomy  for,  48 
Pick,  285 

Porro  operation,  420,  421 
Portio  myomata,  394 
Posterior  vaginal  celiotomy,  1 7 

as  step  in  vaginal  hysterectomy,  54 

drainage  after,  53 

for  delivery  of  adnexa,  38 

of  uterus,  38 
for  differential  diagnosis,  28,  48—54 
for      differentiating      hematocele 

from  parametritis,  48 
for  drainage,  47 
for  examination,  37 
for  exudates,  48 
for  ovarian  cysts,  38 
for  paramatritis,  posterior,  47 
for  pelvic  abscess,  47 
for  peritonitis,  48 
for  replacing  incarcerated  uterus, 

37 
for  retrodisplacement,  47 
incision  for,  17 
irrigation  after,  53 
technic,  17 

to  loosen  adhesions,  37 
uses  of,  28 


Pregnancy,  extrauterine,  358.      See  also 
Ectopic  Gestation. 
intrauterine     and    extrauterine,     pos- 
terior  vaginal   celiotomy   to   differ- 
entiate, 28 
Prolapse  of  bladder,  209 

of  uterus,  anterior  celiotomy  in,  60 
causes,  206,  207,  208 
colpoperineorrhaphy  in,  high,  249 
descensus  vaginae  with,  205,  210 
descent  of  bladder  in,  209 
elongated  uterus  in,   209 
enterocele  in,  210 
hypertrophied  cervix  in,  210 
inelasticity  and,  207,  208 
levator  ani  muscles  and,  206 
perineal  repair  after,  210 
rectocele  in,  210 
repair  of  perineum  after,  210 
retrodeviation  in,  209 
subinvolution  with,  206 
total,  205 

amputation  of  cervix  in,  235 
operation      for,      after-treatment, 
281 
results,  281,  282 
operative  technic,   210 
prevention    of    conception    after, 
217,  219 
vaginal  fornix  in,  209 

lumen  after,   210 
variations,  208 
Pryor,  48 
Pyosalpingectomy,  vaginal  route,   115 

Radical  vaginal  Cesarean  section,  419 
Rectocele,  causes,  206 

operation  for,  210,  265,  266 
Retrodeviations,    anterior    vaginal    celi- 
otomy for,  129 

choice  of  operation,  130 

correction  of,  209 
Retrodisplacement,      posterior      vaginal 

celiotomy  for,  47 
Retroflexion,  anterior  vaginal  celiotomy 
for,  129 

vaginal  fixation  for,  58 
Retroversion,  anterior  vaginal  celiotomy 

for,  129 
Round  ligaments,  shortening  of,  60,  143 
by  vaginal  route,  60,  130,  154 


INDEX 


449 


SALi'iNG()-<_)(H'ii()Ki';("r(.)M  Y,     anterior    va- 
ginal route  for,   i  14 

Sanger,  58,  13  1 

Cesarean  section,  420,  421 
vaginiil  celiotomy,   13  r 

Schauta,  60,  69,  70,  347,  349,  359,  360 

Schuchard,  399 
incision,  399 

Schucking,  131 

on  vaginal  celiotomy,   131,  132 

Sterility,  artificial,  166 

Suspension  sutures,  how  to  pass,  142 

Sutures,  fixation,  how  to  pass,  142 

Thomas,  38 

T-incision,  89,    144,    145 
Transverse  incision  for  posterior  vaginal 
celiotomy,  18 
in  separating  bladder,  72 
Tumor,  cj^stic  unilocular,  operation  for, 
114 
ectopic,  358 
ovarian,  359.      See  also  Cysts,  Ovarian. 

Ureters,  separation  of,  77 
Uterus,      conservative      operations      on, 
vaginal  route  for,  117 

delivery   of,  by   anterior   vaginal   celi- 
otomy, 103,  142 
by  posterior  vaginal  celiotomy,  38 

elongated,  209 

fibrotic  change  in,  283 

incarcerated,    replacing    by    posterior 
vaginal  celiotomy,  37 

malposition   of,    anterior  vaginal  celi- 
otomy for,  113 

myomata    of,     anterior    vaginal    celi- 
otomy for,  129 

prolapse  of,  205.      See  also  Prolapse  of 
Uterus. 

retrodeviations     of,     anterior    vaginal 
celiotomy  for,  129 
correction,  209 

separating  of  bladder  from,  71 

splitting  of,  in  hysterectomy,  366,  381, 
382 

vagino-suspension  of,  143,  149,  151 

variations      from      normal      position, 
208 

ventrofixation  of,  209 

vesico-suspension  of,  143,  147 
29 


Vagina,  narrowing  lumen  of,  210 

prolapse  of,  elevator  ani  muscles  and, 

207 
roof   of,   restoration   to   former   eleva- 
tion, 209 
Vaginal   and   abdominal  routes,    choice, 

64 
celiotomy.     See  Anterior  and  Posterior 

Vaginal  Celiotomy. 
Cesarean  section,  407 

in  eclampsia,  418 

indications,  417 

Metreurynter  incision,  422 

minor,  431 

radical,  419 

technic,  409 
fixation  after  childbearing  period,  161 
by  anterior  celiotomy,  60,  130 
development  of,  132 
dystocia  in  labor  after,  131,  139,  153 
early  technic,  132,  133 
for  descensus  uteri,   162,   178 

position  of  uterus,  178 
for  retroflexion,  58 
labor  and,  131 
methods,  143 
passing  of  sutures,   142 
tautness  and,  197 
hysterectomy,  283,  363 
clamps  in,  366,  382 
disadvantages  of,  363,  364 
history,  61 

inverted-T  incision,  363 
mobility  of  uterus  and,  364 
oozing  in,  365 
posterior  vaginal  celiotomy  as  step 

in,  54 
simple,  283 

after-treatment,  340 

completion,  339 

entering  peritoneum  in,  321 

for  fibrosis  uteri,  286 

indications,   283 

ligation    of    broad    ligament    in, 
292,  321,  322 

silk  ligatures,  340 

technic,  286 
splitting  uterus  in,  366,  381,  382 
hysteromyomectomy,  399 
myomectomy,  124,  392 
operations,  development  of,  131 


450  INDEX 

Vaginal   suspension  by  anterior  vaginal  Vesical    calculi,    vaginal    celiotomy    for, 

route,   130  89 

wall,  anterior  celiotomy  for  separating  fistula,  vaginal  celiotomy  for,  89 

bladder  from,  78,  89  Vesico-suspension,   130,  143,  147 
Vagino-suspension,   143,   149,   151 

cystocele  and,  160  Wertheim,  60,  61,  431 
Veit,  419 

Ventro-fixation,  209  Zweifel,  58,  417,  419 


^^COLUMB.U^N,VEgRS,m,B^RAR,ES(hs,.s,x, 
Vaginal  celiotomy 


2002216400 


